The Corona Dilemma.

Consider the shown picture where you are the decision maker who can pull the lever of the train tracks to avoid the coming train from going straight. If you do not divert the train, one person, John, will get run over. He is elderly and suffering from many diseases. You know him personally and all his friends and family are watching you. They are all shouting at you to divert the train, claiming it is the moral and safe thing to do. You know that if you do not pull the lever, your life in the society you live in is over.

If you pull the lever, the diverted train will run over 50 random people from all over the world as the train drives through them, including people in your own country. Yet these people and their friends won’t know where the train came from that hit them.

What do you do?

And more importantly, because it is obvious what anyone with a modicum of self-preservation would do, what institutions can you think of that would lead to a different choice?

Over the fold I enumerate why I think this is roughly the tradeoff that has faced humanity over the coronavirus, where the options represent letting the virus rage unchecked (the train drives streight) or put whole countries into isolation, destroying many international industries and thus affecting the livelihoods of billions, which through reduced government services and general prosperity will cost tens of millions of lives (the diverted train).

If you don’t like my back-of-the-envelope numbers please provide an honest alternative numerical assessment: anyone can quibble with numbers of others but it only becomes a discussion if you give a reasonable counter-estimate.

Many believe we are currently saving tens of millions of lives via our response relative to taking no drastic actions. When pressed, some say the fatality rate of “letting it rage” could be 5%, which is then used to say we are saving 200 million people. Some even claim that the deaths from coronavirus would seriously disrupt the workforce and thereby the economy.

Let’s take the last issue before we address the question of death rates.

The fact that deaths in the working age population from a pandemic can have effects on the economy is well-established. The Spanish Influenza that wiped out maybe 50 million people in 1918-1920 had a large effect on the world economy because it took out so many healthy people aged 18-40.

What do we know about the fatalities from the corona virus?

The Italian statistics just released are probably the most comprehensive to date. As a new report of March 17th (https://www.epicentro.iss.it/coronavirus/bollettino/Report-COVID-2019_17_marzo-v2.pdf) showed, some 99% of the younger cases of coronavirus deaths were among people with pre-existing serious conditions. Furthermore, the average age of those who died was about 80.

It should be clear that people aged 80 with other serious conditions are not a significant fraction of the workforce.

Then the death toll of the virus in a “do nothing” scenario. Some use the figure of 5% death rates as the high-end estimate, for which one could cite World Health Organisation numbers.

The 5%  is just highly misleading. None of the modelling experts expects anything like that.

The 5% is the high-end estimate of the death rate among individuals diagnosed with the virus. Yet, in most places, including the UK, only the very serious cases get diagnosed at all. Moreover, there are “silent spreaders”: people running around who have or had the virus without knowing it, having very mild symptoms or none. That number is very hard to know as our only estimates are model derived, but for every diagnosed case there could easily be 5 or 10 people running around who have it and never will know they had it (unless randomly tested). Researchers are trying to find this number now by looking at how many people have antibodies rather than whether someone is ill.

So my own best-guess for the total fatality rate for the coronavirus should the whole population get exposed is 0.2%. That corresponds to the death rate on the “Diamond Princess”, a cruise ship with over 3700 people on it that got quarantined in Japan for a month when cases were found. All on board were probably exposed, a bit over 700 on that ship were found to be infected, and only 8 died. This suggests only 1 in 5 have it long enough to be detected and even among those detected via frequent testing (which will give you a much higher number of cases than in one-off random testing) only a little over 1% dies.

One might object that a cruiseship like the Diamond Princess wont have the most unhealthy people on it, but then one should also say its passengers will be much older on average.  Since every year 1-2% of the population die, 0.2% is basically the death toll of 2 months.

These reasons are also why the measured death rate differs so much between countries: in South Korea, where they did a lot of random testing and hence picked up more of the very mild cases, the death rate was 1%. The current death rate in Germany is only 0.3%, again probably due to huge random testing. In Italy and Spain, where only the more serious cases ever made it to a test, the rate is 5% or over. Other differences are the structure of the population, with more old individuals in Italy than in, say, Wuhan. And of course, it is the case that good medical care reduces fatalities, or should we say, postpones fatalities to a later date.

Indeed, it has also been reported that in Italy only 12% of the death certificates claim direct causation by coronavirus (rather than being “one of the causes”). So even in Italy on closer inspection the fatality rate among identified cases is probably not much higher than 1%.

This is probably also why the actual numbers of deaths are so low relative to other major diseases or natural causes. Every day in the world, 3,000 people die of traffic accidents and maybe half a million people die from old age and other causes. The worldwide death toll of corona is even now no higher than a thousand per day, or 0.2% of the usual human death toll per day. Even in Italy, the corona virus fatalities (when properly measured) are dwarfed by the 2,000 or so “normal deaths” per day.

Failing to put corona deaths in such a context is part of the cause of the panic. Not just newspapers are guilty of this, also many health advisers and professionals who are not keeping a cool head. One needs to give reasonable middle-of-the-road estimates for how many people would die. People who claim 200 million might die from the virus choose the route of hyperbole. Not helpful, not safe, and not based on evidence.

Even reasonable death tolls from the virus are misleading because of the fact that the corona virus deaths are so heavily concentrated among individuals with very little remaining life left. Like the UK health system, that openly adopts QALYs (Quality adjusted life years) as the thing it cares about, we should look at “whole lives lost”, or “years of life lost”.

You’d need a good model to do this properly, but I can make a reasoned guess. Since life expectancy in Italy is 83 and the average age of death is 80, a simple rule of thumb would have it those who died had 3 more years left on average. This is obviously not a proper calculation[1], but I don’t think it will be far off given how even among the old, it’s the relatively unhealthy that died. Indeed, if we’d adjust for the quality of life, 3 more normal years is a generous assumption.

So with these basic numbers in mind, let’s work out the likely tradeoffs being made on the corona virus, where the scenarios would be “no containment response whatsoever” (let the train roll) versus the reaction we have had.

Even if no containment would mean there are 200 million deaths from this virus, that would cost the average world citizen 0.08 years of life, which is 600 million years of life lost divided by the world population of 7.7 billion people.

If the economic damage from the panic and disruption caused by taking this virus so seriously via economic self-isolation costs 50 million whole lives, the average of the world under that scenario loses 0.5 year of life (6 months). Under a more reasonable estimate of 0.2% total mortality rate of “do nothing”, we’d be talking about 15 million death, or 0.007 years of life of the average human.

So if I compare my best-guess estimates, then the loss of life of “do nothing” would have been 0.007 (2 and a half days per human) and the cost of our actual response equals 0.5 (6 months). That is a ratio of 1:70 in terms of length of life. Diverting the train to save John costs a whole village.

But even taking the wilder estimates around of the loss of do-nothing, the expected loss of life from the economic panic dwarfs the loss of life in the worst-case-scenario.

This really does raise the question what else we could have done and how to do things next time. I understand the extreme stress of doing nothing as the train hurtles towards a loved one, but for humanity as I whole I believe our panicked response has been disastrous. We have lost perspective on the damage we are doing whilst staring at something closer by.

So the issue is whether there was a middle way and what structures we need to make it politically feasible next time around to take that middle way.

 

[1] Yes, there is a difference between life expectancy at birth and condition on being a certain age, so I am taking an extreme short-cut to a much more complicated modelling issue (I have estimated duration models on mortality and taught them to PhDs). Still, the implicit argument that those who died had another 3 years to live on average seems rather generous if you look at the Italian data.

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42 Responses to The Corona Dilemma.

  1. desipis says:

    Paul, I’ve criticised your modelling in a comment the other thread, in this thread I’ll take a different tack.

    You’re argument boils down this – Sacrifice the weak and vulnerable today to create a stronger, better in the future.

    That is to say, your policies are ethically on par with a Nazi eugenics program.

    • murph the surf. says:

      Humm.

    • paul frijters says:

      the truth is exactly the opposite desipis: who do you think is actually worst affected by the economic meltdown? The young and strong, who can divert their lifetime working hours to new tasks and build up their savings> Or the old and weak who relied on pension funds and assets that have now been decimated? The answer is the old and weak. Only a fraction of them die from this virus, but nearly all of them have been strongly negatively affected by the meltdown.

      So among the 50 driven over by the train are also several old and weak.

      However you slice it, desipis, the actions taken have been a monstrous self-inflicted mistake for everybody. And for once I do not blame the politicians because I think they are doing their best, facing huge new pressures. No, its the panic in the population and the blindness in the health profession to the economic damage that were the main causes.

  2. Toby Phillips says:

    Hi Paul, I appreciate this more detailed articulation of your position. Indeed, I find the logic behind the calculations here to be more plausible – you are presenting a coherent model.

    However there is still something missing for me, which makes the conclusions unsuitable for decision-making. The “actual response” scenario counts economic cost (converted to approx. 50 mil full lives, or 3,850 mil years, you say), whereas the “do nothing” scenario counts only health cost (approx. 600 mil years, you say). Assuming these numbers are correct, they still miss that the “do nothing” scenario has severe economic cost in addition to the health costs you estimate. Policymakers need both sides of the ledger to balance these real trade-offs.

    You didn’t like the modelling I referred to in my previous post because it was 15 years old. Please do check out this working paper released just yesterday from economists at Northwestern: The Macroeconomics of Epidemics. They have constructed a model that tracks both the epidemiological and economic effects of a pandemic.

    Partly it supports your argument: their “containment” scenario leads to a much deeper recession than their “baseline SIR-macro” (do nothing) scenario. But crucially, they have another scenario that acknowledges how the behaviour of economic agents will change as a pandemic spreads, supplying less labour and consuming less goods as people. This seems to reflect reality better than your model, and in their model, it leads to a recession just as bad as “containment” but with more deaths.

    Let me just quote them:
    “An important concern in many countries is that the healthcare system will be overwhelmed by a large number of infected people. To analyze this scenario, we consider a version of our model in which the mortality rate is an increasing function of the number of people infected. We find that the competitive equilibrium involves a much larger recession, as people internalize the higher mortality rates. People cut back more aggressively on consumption and work to reduce the probability of being infected. As a result, fewer people are infected in the competitive equilibrium but more people die. The optimal policy involves a much more aggressive response than in the baseline SIR-macro economy. The reason is that the cost of the externality is much larger since a larger fraction of the infected population dies.”

    • paul frijters says:

      Hi Toby,

      glad to see you are starting to switch your position. Taking a truly broad view is a tough gig in these days of mass hysteria, but even more important for it.

      I have drawn up many models in my time and am still doing so, including whole population mental health models and models of large recessions. My original post was thus simple because it needed to be easy to digest, but there was a lot of background thinking behind nearly all stated numbers as I hope you will see from my answers in that post to various questions.

      The scenario in the paper you link to is basically irrelevant for the corona virus. The reason for that is that the model they set up is one of identical agents, ie their agents do not age, nor do some have co-morbidities. They hence have the non-infected behave as if they have an equal chance of getting a serious illness as those getting the illness, which is how they find large labour supply and consumption effects. The reality of the corona virus is that the effects on healthy working age people are almost zero. Hence they would not rationally to do much adjusting of their consumption and working time at all, unless of course they are lead to panic and have all kinds of false beliefs about how it applies to them (which is, btw, not a possibility in the model you linked to, but clearly the key consideration in reality).

      Papers like that, which put in a huge effort to come up with a scenario in which the panicked response is reasonable, come a dime a dozen and are tendentious, part of the mass hysteria: in stead of reasobably engaging with the actual structure of the health effects and the economic spillovers in an international context and thus coming to real advice as to what to do at present, it is clear they have started in their corona scenario with the answer they want (containment is needed now) within a math model that is only readable by a few econ geeks but that basically is totally inappropriate. That is not helpful, but part of the problem.

      I meant my first sentence though: why dont you switch sides and join me rather than quibble with a deliberately easy-to-comprehend general post?

      • Toby Phillips says:

        I appreciate the invitation, but I’ll stay where I am for now!

        Although I think the model you present here is coherent, I still don’t agree with the fundamental assumptions: that the _only_ cost from letting the virus run unchecked is measured in health outcomes. It will have an economic impact too, beyond those that get sick.

        As for the paper I linked, I find their assumptions more plausible than yours. Namely that if the virus is left to run unchecked, and people do not believe the government is acting to control the virus, then people will change their demand/work patterns. When you look at the level of deaths per capita in Italy at the moment, I wouldn’t assume that young people would behave “rationally” (as you say) and continue their pre-virus patterns of economic activity. But I suppose we cannot know – no country will take the gamble for us to see.

        • paul frijters says:

          Hi Toby,

          I think you know the answers to the “other costs” question. What I have in mind is treating this virus like any other disease that can flare up, like a particularly bad flu year. I havent seen any new evidence that significant numbers of workers die from this disease, have you? It is true that millions have been too scared to come to work, disrupting many industries, which is down to the panic and for which we should ultimately blame the mechanisms that lead to the panic.

          The panic in my view could have been avoided by having key institutions (particularly the WHO) openly treat this as just another, and not particularly dangerous, disease. The question why the panic flared up so much is important and interesting. It seems to me at the moment that one key reason is that we so quickly became aware of the misery and loss of life associated with the virus. Staring that unexpected loss in the face caused anxiety. People cant judge small probabilities, experts used the occasion to push their barrows, social media and regular media amplified the fear, etc. The Chinese didn’t help by giving the world the example of how to be totalitarian, but the big economic damage only really emerged when the Europeans copied the Chinese, which happened when there too anxiety flared up. The fact that this disease is particularly nasty in a visual sense is probably also a factor: the health carers involved get very distressed and that is contagious too.

          That roughly seems the story at the moment: the inability of the general public to deal with a sudden imminent loss combined with extreme hubris by health advisers and health organisations, happy to egg on the hysteria whilst ignoring the huge cost to health and life of their advice.

          Meanwhile the disaster unfolds. India, with almost no cases and far worse health problems than this virus, copying the hysteria of the West and particularly that of the UK, is now going into 21 day lock down. It has hundreds of millions of extremely poor people, living on the brink, now without income and continuously fed paranoia. I fear starvation and pogroms. It’s horrible.

          • Nicholas Gruen says:

            I fully accept what you say about India – in fact, it really IS a catastrophe which wasn’t fully anticipated in your first (50 million dead) post. It will be far more if India locks down.

            But I can’t agree with you on the rich west. I’m locked down – I don’t want to take a 1% chance of dying which I might have with a history of (mild) asthma and susceptibility to bronchitis.

            And you may have a stronger stomach, but I don’t want ICUs turning away 65-year-olds and leaving them to die. So I support intensive action and bearing the economic burden, though we should have taken it more seriously early – and not seeded Sydney with an extra 103 cases from a cruise ship.

            Extinguishing the virus and building from green zones seems the best way to go.

            Can I suggest you have a crack at posting an estimate of what you think the deaths in India will be from lockdown – I expect it will be horrendous.

            • paul frijters says:

              “I don’t want to take a 1% chance of dying which I might have with a history of (mild) asthma and susceptibility to bronchitis.

              And you may have a stronger stomach, but I don’t want ICUs turning away 65-year-olds and leaving them to die.”

              I hear your fear Nick, but I really think this is where perspective and basic statistics are crucial.

              For one, we are turning away people right now for health problems, condemning many to die. Its a choice made every day every year because of the fact that health resources are finite. A Dutch professor (Ira Helsloot) calculated that merely in terms of costs made in the West, the current response is so expensive as to basically choose to kill 100 by neglect to save 1. That is what fear has done to us: made us oblivious to the opportunity cost of our response.

              Then you personally. It gets to my general point about being more comfortable with death. I probably dont run any realistic risk, nor do my kids, but my dad does, and so do many of the people I love or look up to. So it is personal for me too.

              Still, they will all die eventually, from many different causes, and the extreme orientation on this one to the neglect of others makes the net risk higher for them as well. For you too.

              So put it in perspective: what is the usual chance you die every year from now on? What are the main risks you face? How much health risk have you been willing to take to ensure a better future for your wife and children? What are the health risks you are willing to take when flying to a conference (DVT!) or driving in a car? Etc. Anyway I look at the numbers at the moment makes me believe that even for you personally, the risks in our response are higher than the benefits.

              It is a facet of our mass hysteria that fear has constricted our thinking. We are literally not thinking streight anymore. All we can think about are the latest details of the threat: more people in the US, someone in the neighbourhood, horrifying pictures of slow death, etc. We have become blind to the balance of risks to both ourselves and the rest of the world.

              Don’t let fear do this to you.

  3. Really don’t know what to think , it’s truly awful.
    The AFR yesterday reported :

    “The total number of cases in Italy rose to 47,021 from a previous 41,035, a rise of 14.6 per cent, the Civil Protection Agency said.
    In its most complete analysis of the outbreak yet published, the national health institute (ISS) said the average age of those who died was 78.5 years, with the youngest victim aged 31 and the oldest 103. The median age was 80.
    Some 41 per cent of all those who died were aged between 80-89, with the 70-79 age group accounting for a further 35 per cent.
    Italy has the oldest population in the world after Japan, with some 23 per cent of people aged over age 65. Medical experts say these demographics could explain why the death toll here is so much higher than anywhere else in the world.
    The ISS report, based on a survey of 3,200 of the dead, said men accounted for 70.6 per cent of the deaths and women 29.4 per cent. The median age for the women who died was 82 against 79 for men.
    By comparison, the median age of those who tested positive for the illness was 63.
    A deeper analysis of 481 of the deceased showed that almost 99 per cent of them were suffering from one or more medical condition before catching the virus. Some 48.6 per cent had three or more previous pathologies.”

    Am told that the Italians have been forced to focus on younger patients who have both , more chance of recovery and on average longer to live ,for.
    However even with that sort of plague triage ,if most of the population of Europe get it then god knows how many people in their forties and fifties may be lost before their time.
    Can only pray…

  4. Moz in Oz says:

    if no containment would mean there are 200 million deaths from this virus… which is 600 million years of life lost

    That seems really sketchy to me. On the one hand a non-corona average age at death of 83 sounds kind of reasonable, and an average age of corona-death of 80 means yeah, 3 years early.

    But then I think… this is Japan, and Korea we’re talking about. Coincidentally right at the top of the life expectancy charts. And the expected years to live for someone in their 80s is likely to be higher than average because of all the people dragging the average down who are dead before then.

    There’s also going to be significant excess deaths from the health system collapse. When all the hospitals, and especially the intensive care units, are full of coronavirus patients it’s going to be just too bad for anyone who has an accident or gets some other disease.

    So three years loss of lie seems a bit on the low side to me. But since all these numbers are very soft we will have to wait and see.

    The question is should we follow the UK and let the weak die, or follow Japan and try to keep everyone alive. Politically, and ethically, I favour the latter course if only for the terrible company the former course brings with it. “I have a theory, and I will implement it knowing that millions will die” … Pol Pot or Paul Frijters?

    https://en.wikipedia.org/wiki/List_of_countries_by_life_expectancy

    • paul frijters says:

      Pol pot was cheering at the death of 1 million. You are happy to egg humanity onto a course of action that is likely to kill 50 million. That is exceedingly cruel and selfish.

      As to the rest, what can I say? It is easy to feel overwhelmed by a barrage of numbers and take a “go with the crowd” attitude. Often that is smart. Except in cases where it leads the whole crowd towards disaster.

      I suspect the panic has already cost you dearly. How is your pension fund going? Or the value of your house? And how about jobs in your neighbourhood? Feeling confident about the near economic future of your children or other young people dear to you? Know any friends running hotels, restaurants, or working in airports?

      I am basically saying you are one the 50 Moz.

      • Moz in Oz says:

        Don’t forget that the alternative to killing 50M is a course of action that will almost certainly kill more than 200M. And your preference is the path that does less economic damage and anyway the 200 million are mostly old or weak anyway.

        My response: look at Italy. Don’t be like Italy.

        Part of the “old and weak” that you want to sacrifice are those weak-willed individuals who have chosen medicine as a vocation and will insist on trying to save others no matter what you do. They’ll die of the disease, but they’ll also die from overwork. And even if you bomb the hospitals they work in they will work to save people in the rubble. I’m sure you can run the numbers and come up with an optimal number of hospitals to keep in order to preserve a sufficient number of doctors and nurses.

        It’s not just the raw numbers, it’s your method of calculation. “a whole lot of people are going to die, we should save as many as possible” vs “people are going to die, we must preserve the economy at all costs”. That’s a political statement, however much you might wish it wasn’t.

        FWIW: I’ve been self-isolating for a couple of weeks, my pension fund is probably worth less than it was, blah blah whatever. OTOH, you seem to be suggesting that one proper course of action would be to find the person who set the train in motion and kill them, then stop the train.

  5. Moz etc have a read of this
    https://www.statnews.com/2020/03/17/a-fiasco-in-the-making-as-the-coronavirus-pandemic-takes-hold-we-are-making-decisions-without-reliable-data/

    The author is “John P.A. Ioannidis is professor of medicine and professor of epidemiology and population health, as well as professor by courtesy of biomedical data science at Stanford University School of Medicine, professor by courtesy of statistics at Stanford University School of Humanities and Sciences, and co-director of the Meta-Research Innovation Center at Stanford (METRICS) at Stanford University.”

    • Moz in Oz says:

      I’m not aware of a mechanism by which we could obtain reliable data with which to make decisions. Time machines are currently thought to be impossible, so the obvious means is out, and I’m not aware of any psychic who’s actually made reliable predictions when tested.

      The obvious way to obtain the data that the author above wants is to isolate a set of populations for a year or two and see what happens under different scenarios. For a while the UK was offering to do that but they lost their nerve. Something about looking at Italy and losing their nerve, I think.

      Not that that really matters, by the time they had any useful results the crises is the rest of the world would largely have passed. Hopefully Pol Fritjers and you are able to run round afterwards saying “I told you it was just a minor flesh wound”. But if not you’re going to look even more like sociopaths.

      • Moz widespread fairly random testing, sampling of population, you’ve not heard of it ?

      • paul frijters says:

        you are actually enjoying the destruction the panic is causing, aren’t you? Not just indifferent to the human cost, but taking pleasure from it. You really enjoy cruelty. You want it to go on.

        You poor man. To be reduced to such pleasures.

        • Moz in Oz says:

          John: random testing using what exactly? The Chinese have been systematically taking temperatures since almost day one because that’s the technology they had. We’re only just now seeing fast specific testing become widespread, and even so those tests are still in limited supply.

          The option of “don’t test people we think might be infected, test random people” was there, but has not been much used.

          The good news is that epidemiologists have a lot of practice at this stuff, and are well used to working with poor data. They have been, that’s how we have the predictions we’ve got.

          Paul: No, but I feel obliged to respond to your various sociopathic mutterings for fear that people might take you seriously. I still remember the weird #metoo tantrum from you that Nick published here.

  6. Feel that Paul is right to raise this.
    While the costs of doing nothing have been foregrounded.
    The costs of locking down the worlds economy for ,at the least six to twelve months, only to find that the virus is still lurking and the classic ratio : 0 1 1 2 5 8 13 21 36 57 etc still applies to it, have not got enough attention.

  7. Kien Choong says:

    Thank you for discussing this interesting (and important) issue.

    I think a difficulty with letting Covid-19 spread is that the demand for treatment is expected to exceed the capacity of the health system by 8 times (per the Imperial College study), and so arbitrary choices will have to be made about who gets treated and who does not. I realise a severe recession also results in arbitrary deaths, but no one is forced to decide who dies and who doesn’t. Very tough problem!

    If we did let Covid-19 spread, it seems to me we would have to come up with a feasible way of treating everyone – e.g., at home. We would need to spend big on health! So (thinking aloud) maybe the message to government that we can avoid a deep recession if we adopt modest containment/mitigation measures and spend big on health – e.g., increase the health budget by 50 times or something!??

    • paul frijters says:

      thanks Kien for truly engaging. You are keeping a cool head.

      Yes, if I were to hazard a guess on what the optimal course of action would have been for governments, then based on the information at the moment I would say:

      1. No massive social isolation but targeted isolation.
      2. Massive increase in medical capacity to deal with the emergency numbers. So an industrial effort on ventilators and the like. Ditto for pushing through trials on vaccines and the like.
      3. Rationing of limited medical resources on the basis of age and prior health status.
      4. Treat this disease like other diseases. Encourage normal life to proceed untroubled. This means realistic information spreading about who should not really worry about their own health and the actual scale of the issue relative to other health issues. To those who want to shut down the economy, bring out the information on 1929 and the collapse of the soviet trading block in 1990 to show the huge loss of life from those. Dont give platforms to the doom sayers (of which there are always plenty).
      5. Have more open and honest conversations about death, which will come for us all eventually. We need to get more comfortable with it and less paranoid about this inevitable part of life, calmly discussing how we can make the most of life in general, not just stare at threats to it.
      6. A strategy for dealing with the spread of panics on social media. I dont have a good sense of what might work, but all the village fools have come out for the corona crisis to egg on the hysteria (see some of the reactions above). We don’t want to close free speech, but, like with election manipulation on social media, we simply cannot allow that to go on and on.

      We are clear already doing 3, but not enough of 2 and nothing of 4, 5, and 6.
      In order to be ready next time for all these we should also think of particular institutions and advisory roles. Clearly for new diseases we need a response institution that includes medics, but is not dominated by medics, also including more broad concerns than those in immediate view. Reform of the advisory part of the WHO is also urgently needed.

      • Moz in Oz says:

        Paul, I fear you’re suffering expert syndrome and a bit of calculated ignorance. 4 is exactly what we’re doing, and my impression is that we’re doing as much of 2 as we can, if not more (arguably some of the scientists working on vaccines are operating outside their field of expertise so perhaps their efforts should be redirected).

        There are multiple groups of experts working frantically to develop vaccines, several groups of both engineers and lawyers working on different aspects of the ventilators supply chain (intellectual property restrictions are being fought out as well). Perhaps you could develop an economic argument for more resources to be spent on vaccine research and production in normal times? The previous economic consensus seems to be that if a vaccine isn’t profitable by itself it shouldn’t exist.

        In your terms: how many other vaccines should we stop researching and lose their work in progress, in order to try to find a vaccine for covid-19? Is malaria really less dangerous than this current virus?

        Manufacturing ventilators etc is a specialised task and the main problem is supply of key materials, the issue typically being that the chain is economically optimal… ie, there is one factory that makes product X and they are awesome at it. Sadly when you want to double supply every week for 10 weeks… no-one builds those factories because we already have one. I read an article recently about the factory that makes the plastic mesh that goes into PM2.5 filter masks where this is exactly the case: the people who make the extruder for that mesh take 6-12 months to supply the extrusion head (a complex machine, not just a plate with a munch of micro-sized holes in it). So what we have is a bunch of near-enough mesh being made and we hope that will do. Meanwhile… limited supply of masks and a lot of cheap imitations on the market.

        If you think 6 is possible then I suggest googling “moderation at scale is impossible”.

  8. Kien Choong says:

    There has been an active discussion among my siblings & cousins about the idea of “herd immunity”. It’s been wrongly portrayed as simply letting the virus spread. (Although the UK government may have used this concept to justify its initial inaction.)

    [warning: speculative and possibly superlicious views below, and apologies if I offend any ethical sensibilities]

    If I understand it correctly, the “herd immunity” idea is that we eventually want life to return to normal, and that can only happen once the population acquires “herd immunity”. The controversy is over how soon/quickly this can be achieved and it’s controversial because shorter time frames implies higher infection levels that likely overwhelm ICU capacity to treat severe cases. On the other hand, keeping infection rate low likely implies a very long time frame of over 12 months (maybe even 24 months).

    My current thinking is that governments simply need to spend big on health, beef up their ICU capacity (e.g., by 5 times or more!), so that the time frame for achieving “herd immunity” can be shortened as much as possible. Whereas the current approach of simply adopting widespread “lockdown” is very damaging to the economy if continued for an extended period.

    Right now the media and medical profession is (understandably) focussed on mitigating Covid-19, but they are neglecting that a bad recession also has public health implications. We need more public discussion on this issue, as we currently haven’t weighed the negative effects of a severe recession (by suppressing infection completely) vs the negative effects of acquiring “herd immunity” (by allowing infection in a controlled way). It may be that the optimal response is still to suppress infection completely. But this needs to be scrutinised I think.

    Paul, maybe you could write an article for The Conversation!

    • Kien for what it’s worth that’s a good summary.
      A further aspect is that the extreme containment measures may not even work , for example am told that “the Royal Society of Hygiene and Tropical Medicine the other day estimated the number of people in Britain who already have or have had Covid-19 at between 6,000 and 23 million.” That’s quite a spread to base policy on….

    • Kien Choong says:

      PS: I wonder about the evidence that a severe recession has health implications. I don’t doubt that claim, but query whether that outcome is conditional – e.g., do countries with better social security do better in severe recessions than countries with less social security? It may be that countries with good social security have better capacity to cope with a severe recession. Might someone who has looked at this address this issue in comments?

      These issues ought to be addressed in public discussion. Democracy works best through reasoned discussion!

      • paul frijters says:

        Hi Kien,

        one of my hats is as a prof of health economics and the issue recessions-health is a big topic.

        Grosso modo, you might say that historians of health and life expectancy have come to see general economic progress (as measured by GDP) as a key driver of length of life. The mechanisms are the obvious ones: better food, better water, better medicine, etc., are all part of ‘economic progress’.

        On the short-run deviation from that general trend due to short-run fluctuations in economic growth, opinions are more divided. Mental health takes a definite knock in a major recession and in the longer run the reduced investments will cost via the GDP relation. but in the shorter run you often see little effect of small recessions on population health, sometimes even the reverse (the well known Ruhm papers).

  9. Peter Siminski says:

    Thanks Paul for delving into controversial and challenging territory with characteristic passion. Very interesting reading. Here are some thoughts:

    It seems you are discussing two conflated ideas here:

    1. The economic downturn caused by Covid-19 has a greater health cost (measured by QALYs or life years lost) than the direct cost of people dying from contracting the virus. This is the main point of your 18 March article.
    2. That a cost benefit analysis (focussing only on QALYs lost, or similar) would conclude that a do-nothing approach is better policy than short term extreme social distancing. This is the main point of your 21 March article.

    It’s important to distinguish these. 1 may be true without 2 being true. But 2 is really what matters. But your calculations draw on (1) and apply them to (2). This invokes many questionable assumptions: (i) That we would completely avoid an economic downturn with the ‘do nothing’ approach. This is certainly not true. Indeed I imagine the hysteria/panic under a ‘do nothing’ approach would be worse, leading to greater social disorder and downstream economic impacts. (ii) that the economic cost of the social distancing option (relative to the do nothing approach) can be estimated by how much stock markets have already fallen. But the size of that downturn occurred before/during social distancing policies being implemented. It has nothing to do with the actual impact of ‘do nothing’ versus ‘social distancing’ on the economy. (iii) that only people who die from contracting Covid-19 are affected under the do-nothing approach. Of course many people who catch it but don’t die will have quality of life affected. More importantly, the health care of millions of others will be dramatically compromised during this period.

    Focussing on (ii) above – this is the key issue I think – what is the effect on the economy of extreme social distancing (versus do nothing). Let me try to put a first order approximation to this. There are so many factors that affect this. But chief among these is the length of the policy’s implementation. Perhaps it really is needed for only a few weeks? That seems to be the current view – that this buys enough time in order to develop far more targeted (less disruptive) containment strategies. Assume it is implemented globally. So, a first order guess at the impact would be to lose 4 weeks of Gross World Product – roughly US$6 Trillion. Massive – but about 10 times smaller than what you used. Furthermore, many people can work from home. And, there will be much inter-temporal substitution of work/production. Putting all that together, let’s say maybe US $2 Trillion. Am I confident about this estimate? Not at all. But I’m confident it’s closer to the mark than your estimate.

    Estimating the relationship between this amount of global income lost and lives (or life-years) lost is another big challenge that depends so much on who loses the income, under what circumstances, and what social support governments introduce. And I don’t think its income per se. It’s the sudden disappearance of income and jobs that matters more. I won’t attempt to quantify this (at least not now). But a few thoughts on that: In Australia, for example, the government’s response has included an almost doubling of the welfare payment rate. That’s huge, and will go a long way towards buffering the shock. This assumes, that implementation hick-ups (which are substantial) are quickly resolved. But where sudden income shocks (and income loss) will really hurt is in developing countries, where the social support will not do much to cushion the impact. How the decisions made by developed countries disrupt the economies of poorer nations (and the health impacts that will have) deserves serious consideration. It’s not on the radar at the moment (at least not that I’ve seen). But it should be.

    In any case, the case for “do nothing” does not look good. That said, I think you are right to try to assess the case systematically (even if it’s just back-of-the-envelope). But I also think it’s important to convey this for what it is – a very speculative exercise whose main benefit is to stimulate thought, discussion, and perhaps some more serious modelling.

    • paul frijters says:

      Hi Peter,

      thanks for engaging. Let me respond quickly.

      One is that I use the term social distancing in the broad sense in the article above and thus also include the close-off of whole economies, the halt in travel, port closures, etc. So in that sense I am basically comparing a “shrug shoulders, expand in health facilities but disrupt nothing” hypothetical versus the whole package of what we have done. This makes the calculation different from a marginal calculation on each additional step, which would be extremely tough to quantify because all the price signals we have (markets, unemployment, growth forecasts, confidence, etc.) are somewhat aggregate and highly influenced by what other countries are doing, making any disentangling into effects of local deviations nigh impossible.

      I do encourage you though to wade through the comments and my reply to those comments on the “10 million” post. Nick Gruen makes a similar point to yours, which is to presume that the lost productivity of everyone doing nothing for 2 months is just the normal productivity for 2 months. As I said in reply, the loss is far higher, probably a multiple of many dozens higher. The reason for that is these supply chains that get disrupted. Once broken, they dont reform. Trading partners have adapted, key people in the chain are doing something else, and uncertainty leads to a hold-up problem.

      Just think of the economy of Poland after 1990, or that of the whole former soviet block. Their economies collapsed by 50%, taking 20 years to get back to the pre-1990 level. That was because of the collapse of the Comecon, which at heart was a set of supply chains. Factories and machinery that were world class almost overnight became scrap metal suppliers because the chains they belonged to collapsed as countries closed themselves to trade in other countries. Within a measily few months that killed the whole economic system.

      Now I am not saying this time is just as bad (I’d be giving far higher numbers for the damage), but you do see the supply chain disruption and the market valuation is that it really is quite bad. The command-and-control economic institutions now being set up are eerily similar to the soviet days and they cant work for any length of time for the same reason.

      I wish I could agree with you that doing nothing is a bad option. I really do. That would give some solace when seeing the destruction of so much of the best of our societies.

      • Peter Siminski says:

        Thanks for clarifying Paul.

        I think there is a lot of truth in what you’re saying. As you’ve acknowledged, quantifying it is hard, but the economic damage is huge and will have many indirect effects on life-years lost.

        But for this discussion to be relevant for informing policy making right now, its only the marginal analysis that matters. So please be clear that you are not advocating a ‘do nothing’ approach in the current situation. What you’re discussing is perhaps more relevant in a “how could we respond differently next time” discussion.

        I think its also important to be mindful of the limitations of a QALYs lost (or similar) approach. To focus only on such a metric, and ignore the circumstances in which QALYs are lost is too narrow. Dead bodies piling up in make-shift locations due to overwhelmed health systems may only represent 3 QALYs each as you’ve argued. But this is qualitatively different to 3 QALYs lost as a dispersed (and perhaps largely unattributed) consequence of economic downturn. If you like, you can incorporate this within a welfarist paradigm – the wellbeing of whole societies is affected when such things happen through people’s interdependencies (as well as their fears for themselves and their loved ones). People would not stand for it.

        • paul frijters says:

          Hi Peter,

          for any country that hasn’t yet adopted these disastrous rules, the advice “no major isolating” stands.

          Even on the marginal though, the consequences are so devastating that immediate lifting of these mass-isolations seem warranted to me, though I do think one wants to go over a reasonable calculation beforehand. Mind you, the higher burden of proof should be on those arguing for continuing the imprisonment and terrorising of the population rather than those wanting to lift them. It is crucial they are made to consider and calculate the full costs of their actions.

          One can of course advocate middle ways, essentially not to save lives, but for the politicians and health advisers to save face . Without an avenue to save face, they are probably going to remain willing to risk millions.

          One can have easy targets for lifting movement bans, things that look like new protocols to deal with the ships in the harbours, etc. It would all be a way to reverse course without admitting to it. To participate in such a way in a cover-up operation surrounding this debacle might well be the only avenue in the short run for those on the inside trying to make the best of it, which must include thousands of civil servants who by now have realised what is going on. They have my sympathy.

          On the issue of the QALY measure, I normally advocates WELLBYs rather than QALYs, which has far more of the mental health suffering and the loss of purpose in it, just as you suggest, but now is not the time to worry about the distinction as the calculation is going to look very similar on this one and using a less familiar metric will only confuse people.

          Btw, it is a deep irony that normally highly unreliable characters like Bolsonaro and Trump are able to see this hysteria for what it is when so few others can. I think that is because they have used fear to intimidate others their whole life. They can spot a competitor when they see one. And they dont want to impoverish the populations they feed upon. What strange bedfellows these times make.

  10. From the AFR
    Mass testing the best way to isolate the COVID19

    I was reluctant to write this article because I am not a virologist but, rather, a statistician. As the coronavirus contagion unfolds, we are starting to see patterns that possibly should be emphasised. The novel coronavirus is now affecting 192 countries and there are nearly 425,000 cases. More than 295,000 cases are active and this means there are probably more than a million infections. Yet the news is not all bad. The data is starting to reveal how to fight the virus.

    The data across 192 countries raises two issues. First, is there is a uniform curve of contagion or does each country have a different curve? In other words, are there country-specific factors that are affecting the spread of this virus? The data suggests there are.

    Second, the data shows the virus is more successful than other viruses because it hides better. Those without symptoms or with mild symptoms are driving the virus: 95 per cent of current active cases have mild symptoms or none at all. The virus has power because it is unobservable. SARS, too, was asymptomatic in many people, but not as many as in the case of COVID-19.

    When we examine cross-country data, country-specific factors are visible. Within Europe, four countries are prominent: Italy with 69,000 cases, 6800 deaths and more than 3400 in critical care; Spain with 42,000 cases, 2990 deaths, and 2600 in critical care; France with 22,300 cases, 1100 deaths, and 1700 in critical care; and Germany with 33,400 cases, but only 159 deaths and none in critical care.

    It is possible that Germany is on an earlier part of the curve and that the contagion in that country had different types of clustering. It is also possible that country-specific factors are in play. For example, demographic factors like the proportion of elderly; environmental factors such as air quality; and social customs relating to how individuals interact.

    The most important factor, however, seems to be how we congregate. Population clusters – whether in bars, at football matches, in schools, in apartment complexes, or in households – are what is driving this contagion. Countries with lower population densities, such as Australia and Canada, may be spared the worst. Each currently has relatively few deaths and few in critical care.

    Social distancing and quarantining are obvious measures to stop the spread of the virus but we should consider other measures for population clusters such as apartment complexes: perhaps the use of thermometer guns or infrared cameras at their entrances, notwithstanding doubts about the precision of these measuring instruments.

    What the data shows is the role of the asymptomatic. It is not only the person sitting next to you who coughs that matters. It is the person who doesn’t cough. That is why it is important to isolate the asymptomatic. The virus depends on the spread from the asymptomatic to the vulnerable. The segmentation of the asymptomatic from the vulnerable is the key to fighting the virus. It is not sufficient to identify the virus ex-post after the symptoms appear. It must be identified before the symptoms show.

    The lesson is from the town of Vo, where the first death occurred in Italy. All residents of Vo, more than 3000 in all, were tested by the University of Padua. When 89 people tested positive, they were isolated. In the second round of testing, only six were found to be infected and they remained in isolation. Vo has had no more fatalities and a 100 per cent recovery rate. The way to beat the virus is to find it and to isolate it.

    The challenge for Australia is how to initiate mass testing. That should be the highest priority of government at all levels. We must isolate the virus, not the people. The only way to do that is to test.

    We should begin by testing everyone in nursing homes, in hospitals and everyone at higher risk. But we must also find ways to test those who are not at risk and who are asymptomatic. That means we must begin random testing, not just the testing that follows the identification of an infected person. We must sample the virus in the general population, just as we do with voting.

    Random testing is the key to stopping this contagion until we can mass-test the entire population. If a billion dollars were spent on testing and isolating the infected, we may save billions in the months ahead. Testing has to be prioritised. To beat the virus we have to find it and isolate it.

  11. Raul says:

    Fear and histeria will kill far more than the virus, through very severe socioeconomic consequences of bad policy measures to tackle this coronavirus crisis. I think Paul is in the right path, and it is honest and bold enough to say it. Most of those who realize just keep silent. In Spain in any normal year there are even 20k deaths for other respiratory problems. Woth months of more than 4k. Spain is top2 affected country right now, and deaths in more than 2 months are less than 4k. However, in next 10 years many more people will die or live far worse in Spain than they would have with a different decision on the “train diversion” Paul mentions

  12. Dean Travers says:

    Excelent article introduced well with the train example highlighting the cognitve biases behind the issue; our policy response is motivated by an aversion to tragedy in our faces and we are yet to seriously estimate the cost to lives of lost jobs and social isolation. The quick calculation provided is a good start and has initiated some good rational discussion in these comments. If we extend the analysis to an individual country level, the impact of COVID-19 unchecked on a rich country’s average life expectancy would be dwarfed by the difference in average life expectancy between rich and poor countries, but this difference does not capture the public immagination. Alternatively, if we consider other public health policy measures on the menu for any specific country you would not have to look hard for simple measures that would save 1,000s of lives per year (eg assume organ donation by default for accident victims with an opt out possiblity as opposed to the contrary, which is the usual approach). For good or for bad, our political leaders manage perceptions not problems.

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