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 low-level exposure 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.  And it is likely all the passengers will have had a somewhat high exposure. In a “do little”  scenario, most people in the population will not get a high exposure, just as in a regular flu season not everyone in the population gets exposed. 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.[1] 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.

 

[*] Update 21/4 Of course more passengers died since, as you’d expect from a boat with 3700 old people, muddying the water on what can be learned with later data from that ship. However, there is more research coming in on the likely death rate if the whole population were exposed. A recent German paper put the infection-fatality death rate at 0.37% based on finding that for every positively tested person there were 7 times more with antibodies. Yet, given how the more frail are probably also more exposed (see the Ionnanidis video John Walker linked to in the comments), and that there seem to be people who are not “infectable” anyway (the very young), the 0.37% is still an overestimate to what would happen if the whole population got a low exposure. Relevantly, a recent Standford study puts the death rate between 0.12% and 0.2%, essentially based on antibody findings in random samples in the US. So 0.2% is still looking like the right middle-of-the-road estimate of the more contemplative studies, certainly if we think of the fatality rate in a “do little scenario”, which will be far lower than the infection fatality rate].

[1] Yes, there is a difference between life expectancy at birth and conditional 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. [UPDATE 21/04: Andrew Briggs kindly provided a simple excel tool based on UK life tables to calculate the average number of lost QALYs if one knows the age and comorbidity distribution of the victims (which he doesnt quite have: he has the age distribution). He shows the QALY loss given the current age distribution of victims in the UK is between 2.25 (if there are strong co-morbidities) and 4.90 (few comorbidities). Given the high prevalence of co-morbidities, my initial eye-balled guess of 3 QALY loss per death is still looking reasonable.]

 

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100 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.

      • athanasius calliafas says:

        Paul you forget that the politicians based their decision on flawed modelling (gigo as has been shown with Ferguson’s model who also was the culprit in the unnecessary extermination of 3m cows in the so called mad cows event) and very little availability of data. In that respect their decision was diabolical. As a CEO of a company would you make a decision on hearsay and no facts.

    • Tamara Clements says:

      The problem with this comparison is that the Nazis were in a situation where they were choosing between 0 deaths and millions of deaths. The millions of deaths happen in the scenario where they activate eugenics. The 0 deaths happen if they do nothing. Over and above deaths, doing nothing does not cause anyone extreme suffering, whereas a holocaust clearly does.

      We are in a completely different scenario. In a pandemic, we can do nothing and experience a certain number of deaths, and the associated suffering of mourning among certain survivors. Yet if we do something we will reduce the number of pandemic deaths but at the cost of a) other people dying (whether or not the number is the same as the number of pandemic deaths we prevent) and b) extreme amounts of suffering placed on the survivors.

      Unlike in the Hitler scenario, there is no option that causes no suffering, so we have to choose between the “do nothing” suffering and death and the “do something” suffering and death.

      This is why in the pandemic there are no easy choices. In this case it is reasonable to start trying to figure out which choice causes less suffering.

      The argument that doing nothing disproportionately negatively affects the weak and vulnerable is true in one sense (as the virus will disproportionately affect the old and sick) but it does not take into account that the economic cost of doing something will disproportionately affect what I would argue is an even more vulnerable group – poor people in developing countries. These are people that, if they live, can have decades of life ahead of them. Yet estimates suggest over half a billion people sliding back into extreme poverty, primarily due to lockdown, and over 130 million sliding into starvation, primarily because of lockdown. Lockdowns in the West will affect poor people in developing countries, as we buy so much from them. As a result, deaths from diseases of poverty are likely to rise. Deaths from diseases of poverty (15 million a year) are already responsible for over 1/4 of annual deaths , and many of the people who die are young children in developing countries. Personally, I find it distasteful to suggest that we should sacrifice an African child, potentially with decades of life ahead of him, who already has all the cards stacked against him, for an 80 year old in the West who has already lived a full life.

      Yet this is just one other factor to consider. The issue of life years is important – the risk of coronavirus death tallies up exactly with background death risk (i.e. the more likely you are to die if you don’t catch coronavirus, the more likely you are to die from coronavirus). So coronavirus deaths disproportionately affect people with few life years ahead of them. So even if the deaths from not controlling the virus>deaths from controlling the virus by some way, we could still be losing more life years by controlling the virus.

      Furthermore, no matter how weak a minority is, is it really fair to say that there is no point at which the cost in suffering of saving that minority is too great? If the cost of saving 5 vulnerable people’s lives were that 1 billion people had to be unendingly and excruciatingly tortured for 40 years each, would you really say that it would be more moral to save those 5 vulnerable people? If not, then you agree that there is a point at which the majority is being asked to sacrifice so much in order to save the lives of the weak and vulnerable from coronavirus, that it would overall be more moral to let some weak and vulnerable people die. It is not easy to say whether lockdowns are too much of a sacrifice, but at the very least we have to accept that they will likely involve saving some tens of millions of lives at the cost of devastating (and I don’t think that is too strong a word) the lives of over a billion across the world. That devastation will kill some and cause awful suffering to hundreds of millions of others. This is really not something to be lightly dismissed.

      Your comparison to Nazi Germany is not only a poor comparison to the choices we face here; it trivialises the suffering of over a billion people worldwide who will be impoverished, starved and in some cases, killed by a lockdown strategy. Unfortunately, too many seem ready to far too easily dismiss this suffering as irrelevant or not worth considering.

      • Tamara Clements says:

        Btw the “over a billion across the world” is a reference to the Internal Labor Organisation’s predictions that 1.5 billion could become unemployed across the world due to the coronavirus recession, which will largely be a lockdown-caused recession, not an inevitable consequence of the pandemic itself.

  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.

        • Moz in Oz says:

          Medlife Crisis addresses your plan:

          • Nicholas Gruen says:

            Thanks for this.

            • murph the surf says:

              I apologise for the duplication and also want to thank the poster for the excellent video.
              An example though not at such a grand scale as Covid 19 was the effort to eliminate the equine influenza outbreak in NSW some years ago.
              Rather than accept an outcome leaving the infection endemic and when a vaccine existed authorities pursued elimination.
              A minor fear I harbour is long term consequences on the health of those who recover. Viruses can prompt autoimmune diseases and unpleasant secondary disease – HIV is now understood the weaken the integrity of the coronary arteries and aorta , this novel virus , from an unknown source still is largely not understood.
              If those who recover suddenly start having acute cardiac failure or the onset of nerve demyelination leaving even a small percentage with MS type problems , what relevance are calculations based on just mortalities?

              • Murph
                A number of those who recovered from the Spanish flu went on to develop a extreme rapid form of Parkinson’s syndrome
                They were the group that the book Awakenings was about.

  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.

  13. Christoph Hennig says:

    I think you miss an important point. Reactions to the corona virus are partly due to “mass hysteria” as you say, that is to a psychological phenomena. But basically the actual reaction is not grounded in psychology, Modern states, at least European states, have their basic legitimation in the protection of their citizens: protection of their property, protection against violence and namely protection of their lifes. No Western state can afford to let people visibly die when they could be saved by government action. The rational calculus you propose doesn’t work here. A state following your strategy would appear in the eyes of many citizens as a “murder state” and people would feel authorized to rebellion or at least to disregard of the law which in turn would induce uncalculable social and economic costs. This is, in my opinion, a structural constraint which makes your “rational-choice” approach unrealistic.

    • paul frijters says:

      Hi Christoph,

      the politics is definitely very difficult and I certainly dont have a great answer as to what to do on this.

      Yet, I dont really think its about protection of life, because then we should have seen the same reaction with previous bouts of flu, air pollution, or things like traffic deaths. Our governments allow many health risks without this reaction. Allowing smoking, which kills far people more every year, is a well-known example.

      What is clearly true though is that our governments had little choice but to ride the wave of this hysteria. The call to “do something” was just too overwhelming, from the whole population.

      That is why I pose the institutional question: what can we build that would not react this way.

      And there is the question why this particular thing generated such a hysteria as to overwhelm the ability of politics and calm rational thoughts to drive decisions. Can these kind of waves be prevented from gathering such force?

      All these questions were part of a subsequent post: http://clubtroppo.com.au/2020/03/26/6-post-corona-institutional-questions/
      No real answers though :-( Maybe you have some?

      • Three things
        A “ to let people visibly die ”
        B ten percent of eighty year olds will die in the next year
        C in modern societies ,most of the time, death is physically and psychologically hidden .

      • Christoph Hennig says:

        I agree it is not about the protection of life, that’s why I said “No Western state can afford to let people visibly die…” It is about expectations and images which are as powerful as material facts. I guess that any “rational” approach (in your sense), leading to a considerable number of visible deaths and to a temporary disfunctioning of the hospital system, would have produced images not tolerable for our societies, with potentially very problematic consequences. I don’t say the actual reaction is “right”, I just say it seems in some way logical to me. No real answer so…

  14. Hector_St_Clare says:

    Excellent essay, Paul Frijters. Not sure I agree (or everything) with not, but I definitely agree that a cost benefit analysis is where we need to start, not with high flown rhetoric about “saving lives”.

  15. Jos Gobert says:

    Geachte professor,

    Waar blijven stemmen als de uwe? Sociologen, filosofen, historici?
    Ik ben huisarts, 58 ,en sinds 2 weken genezen van covid met wat verhoogde levertesten en nog wat rommel in mijn lichaam. Nooit echt erg ziek geweest.
    Tegen dit virus bestaat nog niets. En daar stopt de virologische bevoegdheid.
    De oncoloog stopt ook als hij de kanker niet kan genezen, geeft door aan geriater, psycholoog of priester.
    Al 2 weken zie ik niemand meer met hoest en koorts, ook niet telefonisch. Kan het zijn dat het virus sneller uit de normale maatschappij verdwijnt dan verwacht?
    U bent expert en heeft waarschijnlijk gemerkt dat u zich soms vergist.
    Dat kunnen ook onze huidige experten, kijkend naar de proteinekapsels van hun virus of de bezetting van hun ICU. Zij zie overal virus en doden. Maar er zijn ook historici die zeggen dat de Grote Depressie aanleiding was tot WOll.
    Internationale instabiliteit en een aanslag op het welzijn is iets heel gevaarlijks en minstens zo onvoorspelbaar als een ongekende RNA-streng.
    Ondertussen belasten we onevenredig de samenleving. Voor mij 58, valt het mee. Voor mijn kinderen is het al wat moeilijker, vakanties, festivals dromen weg en minderwaardig onderwijs.
    Maar zij hebben een wat rijkere papa. Dus valt het mee. Maar er zijn er anderen.
    Ik zie hen niet vertegenwoordigd in de raden, bevolkt door zestigers, die zeggen “zich goed te kunnen voorstellen”.
    Hoe hoogmoedig zijn zij. Het is onmogelijk om het je voor te stellen. Constant wordt er gezeverd over iets van een nanometer groot en over de economie.
    Jongeren en zeer ouden (en eigenlijk wij ook, hoor) hebben andere dromen en verlangens. Ontmoeten, reizen, risico’s.
    Inderdaad, er zit een grote zwarte blaffende hond op de weg en je kan er 2 jaar in een wijde boog omheenlopen.
    Je moet de hond niet overwinnen maar jezelf en er toch eens een keertje voorbij
    Met achting
    Jos Gobert

    PS Mijn vrouw werd ziek en gloeide. Ik nam haar eens goed vast die nacht. Ik hou al 30 jaar van haar. Ik zet haar geen 2 weken in de veranda. Samen uit samen thuis

    I’m sorry,

    I wrote this to you complimenting you on your essay but it bounced on your e-mail.
    So i’ll add a few remarks.
    Probably worst case 0,4% fatality. I’ll tell you this having been a Covid patient mild form and reading a lot about it.
    As for the Nazi-arguement, it can be applied in the euthanasy debate the abortion debate and now the Corona debate. It’s not worth discussing with people who abolish ratio and shout “Holocaust”
    I’m glad people like you exist. Virologues have a place working out strategies on proteinmembranes in labs. If they have no treatment and no vaccine they should work harder and faster. And leave society to other specialists

  16. Jos Gobert says:

    Estimated Prof,

    Why are voices like yours so absent? Sociologues, filosophers, historics?
    I’m a GP, 58, 2 weeks cured from COVID with still some elevated liverenzymes en some rubbish in the rest of the body. Never seriously ill during my 9 days sickness, only fever.
    As you say, there is no cure against this virus. And there the virologue should stop.
    And leave society to other specialists.
    The oncologue stops when he can’t cure and passes on to the geriater, psychologue or priest.
    For 2 weeks I have not seen anybody in the practice with a cough or a fever. Is it possible for the virus to dissapear faster then expected?
    You are an expert and you must have noticed that once in a while, you were wrong.
    It is possible that our present experts looking at the proteinmembranes of the nanometer virus or looking at the ICU load could be wrong , or biassed?
    They see virus and death everywhere. But there are historics that explain that the Great Depression lead us in to WOll.
    International instability and an attack on individuals wellbeing is very dangerous and at least as inpredectable as an RNAvirus
    In the meanwhile we are sanctioning society basically unevenly.
    For me, 58, at work, It’s OK. For my children ranged from 16 to 32 already harder, hollidays, festivals, dreams gone and inadequate teaching forms leasding only to more sanctions. But they have a wealthy dad. So it’s ok. But what about the others?
    I do not see them represented in the organs and commissions populated by 60+, who are claiming ” they can imagine how young people feel”
    They have some hubris. It is impossible to imagine. Constant talks about the nanometer RNA virus and economy.
    Young people and even the very old (and to be fair we as well) have other dreams and desires.
    Meet, travel, risks, enjoy
    Yes there is a big black barking dog on the pavement and you can avoid it the next two years.
    You do not have to overcome the dog but yourself.
    Courage is a middle, knowing the danger make a proper analysis and face it.
    If you do not know the danger you are just reckless.
    If you run you are a coward.
    This is Aristoteles who was maybe the smartest man that has ever lived

    I salute you with esteem

    Jos Gobert
    PS My wife got sick en was shivering at night. I took a hold of her that night because I knew it was Covid. I love her 30 years. I’m not isolating her in the veranda. Out together together at home

  17. Jan Matthieu says:

    Here’s the text published in the newspaper Standaard

    “You can’t win against a virus”
    Welfare economist Paul Frijters is convinced that the lockdowns cause more damage than we think. The gains in lives saved do not outweigh the quality of life lost through unemployment and economic decline. “The future of our children will be seriously compromised.”
    “Who dares to ask the cost-benefit question,” this newspaper wondered after the first week of the lockdown. Welfare economist Paul Frijters, who teaches at the London School of Economics, not only dares to ask the question, he also dares to answer it. For him it is clear that the costs of the lockdowns in the long term are much higher than the benefits.

    Frijters is a specialist in labor and welfare economics. His main concern is the enormous economic damage caused by the lockdowns. The toll on unemployment, poverty, loneliness and loss of prosperity will continue to be felt worldwide for many years to come, he argues. One can’t directly link the human lives that are lost as a result of the measures to those measures. But they will be there.
    Millions of years of life

    “Due to the economic damage, the public system will eventually be forced to spend less money on health care worldwide than it would have under normal circumstances,” he said on the phone from London. “There will also be less money for road maintenance, increasing the risk of road fatalities. Education will also have to do with less. So we will be less educated, which in turn has an influence on people’s behavior. There are a hundred and one minor causalities that are well documented. To name just one thing, if there is less money for good sewage, it will have an impact on diseases and therefore on life expectancy. ”

    In the posts Frijters wrote on a blog for economists in recent weeks, he gives the example of China and India to clarify the connection between economic growth and life expectancy. Between 1978 and 2010, China’s gross domestic product rose from $ 500 to $ 10,000 per capita. In that period, life expectancy increased from 65 to 75 years. “That was due to improvements in food security, health, social stability and many other factors.” In India, life expectancy is fifteen years higher than forty years ago thanks to the rise in prosperity. If you extrapolate those numbers, the damage from the corona panic could run into the millions of years of life, Frijters says.

    The economic impact of the lockdowns is indeed threatening to become enormous. The International Monetary Fund estimated the magnitude of the loss of wealth to be $ 9,000 billion for the time being. There is a real chance that it will become much more, said lead economist Gita Gopinath this week. Unemployment is rising everywhere, economies are deteriorating, governments are seeing shortages rise. The recession will be the worst since the Great Depression of the 1930s, the IMF predicts.
    Find scapegoats

    Frijters does not rule out the possibility that the long-term effects of the lockdowns may even foster civil wars and famines. That’s not far-fetched, he says. “In India, the lockdown sent millions of day laborers home. If they cannot work for months, they will starve to death. They will look for scapegoats. The Hindus will soon look at the Muslims. In the Muslim community, extremist groups can regroup. That can go completely wrong. We are not that far from civil wars. Economic progress brings peace. If things are going well, people would rather get rich than fight each other. What influence does corona have on that process? ”

    “If things are going well, people would rather get rich than fight each other. What influence does corona have on that process? ”

    How, then, should India have tackled the corona crisis? Frijters’ answer is simple. “The authorities shouldn’t have done anything at all. Dozens of deadly diseases are prevalent in India. Malaria and malnutrition kill many thousands of Indians. It is hard to understand that the country is taking such far-reaching measures to fight a disease that does little more damage than the flu. The improvement of health in India is the result of economic development. If you stop that development, you will be of no use to public health. ”

    “Pretty minor illness”
    In the West, the rise in unemployment is a cause for concern. It is known that a lack of work means a significant decline in quality of life. “Unemployment has risen quickly, but will not fall again just as quickly. We will suffer from it for years to come, ” says Frijters. The loss of quality of life due to the extra unemployment, the feelings of uneasiness and the months of loneliness far outweigh the lives we save by the measures, he argues. For each life year saved, there are, according to a rough estimate, seventy life years lost due to the lockdowns. Frijters calls covid-19 “a fairly minor disease.” Doesn’t he minimize the condition too much? “It is true that we do not know everything about the health effects. In weighing the economy against public health, those who shut it down must provide the burden of proof. You should have proof that such draconian measures are sensible. Now it is the other way around. We cannot estimate the effects, but we will take the measures anyway. ”

    Critics have already noted that Frijters may underestimate the severity of the disease. He assumes that the total mortality of anyone exposed to the virus is 0.2 to 0.5 percent. The figure is based in part on the experience with the Diamond Princess cruise ship. But there is a lot of uncertainty about the actual mortality rate: estimates range from less than 1 percent to more than 3 percent.

    “Mostly it concerns people who did not have much longer to live. You have to balance that against the lockdowns which will make our children’s future a big mess, “says Frijters. “With a real rational consideration, you would come to different conclusions. I don’t see numbers that make it worth compromising the future. ”

    Great Britain, where Frijters lives, initially seemed to make a different decision. On the advice of scientists, the country focused on group immunity. The Johnson administration initially was strongly opposed to a major lockdown. “The Swedes and Russians also went a different way,” Frijters notes. “But it does not seem possible for any politician not to go along with the hysteria. The panic on social media and the open letters from scientists have also changed the course of the government here. ”

    Many doctors warn that the corona crisis will cause a lot of health damage in patients who do not have covid-19. This is because we postpone normal treatments and many no longer dare to come to the hospital. Chris Whitty, the British chief medical officer, has warned against this in so many words. Emergency physician Tania Desmet of UZ Gent also emphasized the danger of this phenomenon in this newspaper. “Delaying care can become an even bigger drama than the corona crisis.”

    According to Frijters, the fact that the emotions win from the ratio also has to do with the way in which the Chinese fought the virus. “The lockdown in Wuhan was a bad example. But the drastic interventions in China made it seem as if we could no longer make any other decisions. This was also because the Chinese quickly declared that their approach was successful. “The reality is that many Asian countries, such as South Korea, Taiwan and Singapore, have taken a very different approach than China. The West chose to follow the example of an authoritarian communist dictatorship, rather than looking at how democratic countries handled it.

    According to Frijters, the result is we are now conducting a gigantic social experiment. “All competent authorities agree: we must move more, we must not be lonely and we must remain active. This is all good for our well-being, our health and our life expectancy. We temporarily put aside all that advice. Two months of compulsory loneliness may prevent the spread of the virus, but it is an emotional damage in the long run. ”

    It remains to be seen how we will interact in the future. Will shaking hands and kissing continue to be as common as before? Or will we be afraid to touch each other? Shall we continue to travel eagerly and build a reservoir of positive experiences? Or do we become anxious and will we not dare come into contact with other cultures any more?

    Take your loss

    Frijters believes that it would have been more rational to just let the virus take its course, despite the wave of deaths that would have resulted. “What could have been an alternative approach? Not doing too much, taking your loss, looking for a vaccine, maybe advising the elderly and vulnerable groups to stay away from places where they may get infected. And for the rest hoping for a quick group immunity. From that perspective, one might even have to encourage groups of people to mix. Otherwise it could take years. You don’t win against a virus. ”

    Frijters compares the economic shock that we now deliberately cause to the Great Depression of the 1930s, or to the collapse of communism in the Eastern Bloc. But can we also make such a comparison with Covid-19? What if it turns out to be as bad as the Spanish flu, which killed 50 million a hundred years ago? That comparison does not hold, he thinks. “We then had a population weakened from the war. Moreover, the Spanish flu took mainly victims in healthy people between the ages of eighteen and forty, while covid-19 mainly affects the elderly with underlying conditions. ”

    These features of the corona epidemic were already known early on, says Frijters. Although the mortality rate initially seemed much higher, “but the modellers soon realized that many more people carried the virus than just those who showed disease symptoms.” That was also why Britain initially focused on group immunity. “It seemed that few people would die who were not at the end of their lives anyway. Then came Italy and the virus seemed more deadly than we thought. The modellers and the vast majority of scientists then went along with the hysteria that arose. ”
    Frijters remains a man crying in the desert, he realizes. “I have a few supporters. I have been interviewed by ten newspapers. I also initially received support from senior government advisers, although I no longer hear from them. But I am convinced that many people are realizing that the lockdowns must stop. “

  18. Nicholas Gruen says:

    Thanks very much for that Jan

  19. Kien Choong says:

    I would dispute the claim that the West followed China’s example in Wuhan. Most Western rhetoric seems to be that there is nothing to be learned from China because it is “authoritarian”, whereas we are “democratic”.

    On the other hand, there are Western experts (including our own Dr Norman Swan) who do think that we need to suppress the virus by imposing severe containment measures. We can legitimately disagree that this is the right course of action, but I would not try to argue that those experts were swayed by China’s example in Wuhan vs independently thinking for themselves.

    I realise there is a lot of negative sentiment about China, so perhaps it is tempting oppose a strategy we disagree with by associating it with China??

    • Kien
      Don’t feel that it’s much to do with sentiments re China as such:

      Unfortunately it seems that the local authorities in Wuhan initially tried to treat the virus as though it was a ‘dissident’ ,suppress the whistle blower ,rather than the disease. And WHO did not ‘hear’ the alarm sounded by Taiwan about, widespread illness in hospital workers in Wuhan, at the very end of December- it wasn’t until the end of January that WHO finally sounded the alarm.
      By then the virus was already in about 15 other countries i.e. it was way too late for effective non-pharmaceutical , suppression-elimination to be realistically possible.

      It could be ages before a working vaccine is available, if ever, and the ability re producing enough of it is also in doubt.( for example the TB vaccine:BCG is also a effective treatment for bladder cancer but getting enough of it to treat just those Australians that need it at times hard work).

      If a strategy doesn’t have an exit strategy . Then it doesn’t really deserve to be called an strategy, rather it’s simply putting off the inevitable, until you run out of puff.
      Shutting down for long enough to get enough ICU units etc in place was is needed .
      However shutting down for long enough to ‘eliminate’ the virus now that it is globally established , that is not a strategy .

      • Kien Choong says:

        Hi, the point of my post was simply that the Western response to Covid-19 was independent of how China responded to Covid-19. There is a lot of negative sentiment towards China in the West. So I merely speculated that associating a strategy (in the West, not in China) with China is a tempting way to discredit that strategy.

        We could perhaps debate the merits of China’s response to Covid-19, but I suspect it would unlikely change your mind?

        • Kien
          I basically agree that the west’s response was and is grounded in western predispositions.
          BTW
          I have long thought that the west’s attitude to China ,in general ,has always had too much of ,a sense of superiority, based on little more than a lack of curiosity.

          However as far as the CPC etc goes , Pierre Ryckmans was nearly always correct.

          • Kien Choong says:

            Hi, thank you for telling me about Pierre Ryckmans. I just finished reading his essay on Chinese attitudes to the past, which (at the risk of oversimplifying) the Chinese preserve in culture, not in stones. It occurs to me that the Jews and Chinese share a similar attitude to the past.

            I’m not sure what Ryckmans wrote about the CPC, but it seems to me that the CPC has changed over time, and I expect it will continue to change, I hope for the better.

    • paul frijters says:

      Kien,

      you may dispute the claim that the West followed China’s lock down strategy, but the fact is that many countries have pursued pretty much the same strategy. Whether they would have done so anyway is a different matter, hard to know, but fact is that the West did follow China’s example.

      Dont understimate either the importance of the example the first mover has, even if others dont like that first mover, nor the underlying awe and regard that China has come to inspire in the West. One may ridicule and belittle an opponent, but the mere fact of doing so means one takes that opponent seriously. And makes it a normal idea to copy his reaction to an external threat….

      So perhaps you see it as a form of flattery.

      My previous “6 institutional questions” already talked further about this issue.

      http://clubtroppo.com.au/2020/03/26/6-post-corona-institutional-questions/

      • Paul
        The similarities are , I believe, a matter of, convergent evolution.
        The west’s public health institutions have long believed that the answer to ‘everything’ is ,to various degrees controls nudges over human behaviour , be it taxes on sugar , fat etc restrictions on this and that or onto actual criminalisation etc.
        And they just like their Chinese counterparts have reacted as thought the virus was a dissident or an academic that wasn’t a ‘reliable chap’.
        Sadly protecting authority will come first ,it will only fall after much human misery has passed,

      • Kien Choong says:

        Perhaps we can say that China’s example shifted a kind of “Overton window” of possible responses to Covid-19 that seems feasible. But surely (or at least in my view) the Western response to Covid-19 reflect their own agency.

        Also wary of “attribution bias” – i.e., the tendency to attribute good outcomes to our own agency, but bad outcomes to circumstances (e.g., other people’s fault).

        Do I want to claim that China’s example has no influence at all? No. On the other hand, it seems false to claim that China’s example meant the West “could no longer make any other decisions”.

        • paul frijters says:

          I totally agree the West has its own agency and should be blamed for its own choices. That is also why I find it difficult to blame the disaster happening in India now on the example of the UK, though it is clear they are somewhat blindly following that example.

          It is within the political realities of the West that after the example of China, no other possibilities were feasible. You saw this particularly strongly in Italy and the UK: a great clamouring of public and “experts” to follow the Chinese example, seen as “the safe thing to do”.

          One lesson for the future is that the West needs to learn why China does what it does, so as to avoid repeating the mistake of following such examples. As I discuss in … that institutional post :-)

          • Kien Choong says:

            Hi, Professor. Thank you for reading my comments and for responding. I don’t have anything further to say that would usefully add to the discussion.

            I agree (with some hesitation) that India might be better off doing nothing, especially if it is true that: (i) death rates associated with malaria etc are as high as Covid-19, and (ii) India has historically done little to address the death rates (whether due to lack of institutional capacity or insufficient political will). However, I’m not really familiar with the situation in India so hesitate to pontificate!

  20. Jos Gobert says:

    Another “problem” we face is the fact that the lockdown was put to us in a dictatorial way. Probably the onely option to act fast.
    As for the exit strategy we are especially in Belgium slowed down by our normal democracy. Suddenly all measures need to pass trough all sort of channels. Parties, committes, unions etc
    We did mess with the normal exponential curve because we could not live with an expected death toll of 30000 people (fast: 60% infection of 11Mx 0,4%). As we ethically rightfully should, indeed.
    But once you start intervening, you cannot stop and freeze. In our democracies we seem to be paralysed. And for virologues the answer is easy. When will the risk be 0. Never.
    So Juli, August, September, October. There really is no difference. My conviction is that we will have to live with an acceptable risk and start shaking hands and hug helped by tools and technology knowing that f.e 1/1000 persons you meet might be infected. The 1,5 meter rule in the long run is ridiculous anyway (only now to flatten the curve acceptable) because the virus actually acts like an airborne virus. Mouth masks might help but measuring the actual risk is what we have been doing for centuries. I know the comparison is fully incomplete but when HIV started everybody suddenly used condoms, after a few years heterosexuals who did not go to a brothel started neglecting but remained cautious and when it became treatable our behaviour changed again. Just like TB, HIV is still killing a lot of people but not in Belgium. If you behave irresponsably you and your contacts remain a risk.
    And we are constantly measuring, measuring and counting. As we do with so many other micro-organisms. As Paul said if we freeze and leave the organisation of our society to the wrong experts you ‘ll end up with a strange community with a far bigger death toll

  21. John says:

    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.

    Put there instead of 0.2% > 1.8% from Diamond Princess (13/712) plus 7 in critical condition and you have whoooole different picture. Not talking about 7 still in critical conditions. And not taking in account side death when health care is overwhelmed.

  22. Hi John,

    as you could see in the post, I used all the passengers as the likely relevant denominator, not merely the ones that tested positive. Even with 2% death rate, the resulting advice would be the same.

    However, lets indeed discuss the 0.2%

    A recent German paper (link to the key bits below) put the death rate at 0.37% based on finding that for every positively tested person there were 7 times more with antibodies. Still, given how the more frail are probably also more exposed and there will be people infected in the past without antibodies, the 0.37% would be an overestimate.

    A recent Standford study puts the death rate between 0.12% and 0.2%, essentially based on antibody findings in random samples in the US.

    So until better studies come along that overturn them, 0.2% is looking like a reasonable figure. Its also the kind of figure I believe the modellers now take into account, but happy to be proven wrong.

    https://science.slashdot.org/story/20/04/11/0231200/blood-tests-show-14-percent-of-people-are-now-immune-to-covid-19-in-one-town-in-germany
    https://www.theguardian.com/world/2020/apr/17/antibody-study-suggests-coronavirus-is-far-more-widespread-than-previously-thought

  23. Kien
    In this (hour long) YouTube https://www.youtube.com/watch?v=cwPqmLoZA4s
    Dr Ioannidis (CV below) gives his perspective on many aspects of the pandemic. One aspect he details is how because Covid19 is very infectious , in some hospitals exponential transmissions from , patients to patients and patients to medical staff and on, were are a big multiplying factor in places such as Italy and possibly in New York.

    In mid to late December Taiwan detected emerging very high levels of sickness in medicos and nurses in Wuhan. Taiwan tried to alert WHO but because WHO had been captured by the Chinese government,WHO did not listen.

    If Italy had known by late January of a high risk of ,in hospital hospital transmissions developing exponentially.They might have taken a different path.

    Dr John P.A. Ioannidis CV “ is a 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.”

    • Kien Choong says:

      Hi, John. Thank you for telling me about Dr Ionnidis. If it is true the WHO didn’t pay attention to Taiwan’s warning, that is regrettable. One could take the view that Taiwan could have found a place in the WHO by acknowledging that it is part of China, just as Hong Kong has been able to work with the WHO as a special part of China. So any problems that Taiwan has had with the WHO is arguably something that Taiwan needs to take responsibility for.

      That said, my own personal view is that China and Taiwan are ultimately jointly responsible for resolving the difficult issue of Taiwan’s status. I would oppose any military solution, but I also think that the move towards Taiwanese independence is misguided. If I were the President of Taiwan, I would seek unification with China on terms that not only preserves Taiwanese autonomy in terms of fiscal, monetary, and even defence independence, but also create an independent constitutional court that will rule on any disputes between the mainland and Taiwan. This way, the rule of law would eventually become entrenched in China itself.

      Many of us reasonably feel that governance in China could improve. Some think that this can be done by shaming China. But Taiwan is uniquely placed to change China through negotiating a rule-of-law based unification with China.

      I apologise for going so much into the Taiwan issue which is unrelated to the main topic of this blog post; but it’s unavoidable if one is discussing the issue of Taiwan’s status in the WHO. If you want to discuss this further, I suggest you write a new blog post on this for Club Troppo? As I don’t feel I should stray so far away from the original topic of this particular blog post.

      • Kien thanks ,
        Taiwan history and all that is a bit too far outside : art , fire history and environmental history for me :-)

        My thought was is : if Italy had only known from the beginning that in hospitals in Wuhan, patient to medico transmission and on to other staff and patients etc was a major problem, then things in Italy and the rest of the world might have been , better.

        • Kien Choong says:

          Oh, I see.

          My impression is that there was just a lot of uncertainty and China had not deliberately withheld information from Italy. I know there is a huge fuss about “cover up” in China, but again, I attribute it to uncertainty, with local authorities mistakenly thinking that reports of a a viral outbreak was unduly alarmist. I don’t think there was any deliberate attempt to cover up.

          For details of the alleged “cover-up”, see http://www.ecns.cn/news/society/2020-03-20/detail-ifzusrwx0569417.shtml . (Suspicious minds might say this is another cover up of the cover up! But I’m happy to take it at face value.)

          The fact that China is now widely accused of “cover-up” reflects the negative sentiment that the Western media has towards China. Or “attribution bias” is at work – i.e., any bad outcome is attributed to “their agency”, not circumstances.

        • Kien Choong says:

          Also sceptical about the counter factual – i.e., Italy would have acted differently. Spain saw what happened in Italy and still ended up worse than Italy. Again, attribution bias at work(?): “If only WHO had paid attention to Taiwan, we would not have ended up this way”.

          • Kien
            just as historians still argue( with validity on all sides) about the causes of WW1 , we will be arguing about the ‘true history’ of Covid19 in one hundred years from now.

    • paul frijters says:

      thanks for digging this up. Very interesting indeed.
      One major implication of this is that the observed death rates are going to heavily overstate the implied death rate if the whole population were infected. This is because the old and frail are actually likely to have been far more exposed than random members of the public, so those with a risk of dying from it are more likely to be in the exposed group.

      That effect can be quite large. At the extreme, it would mean that the observed death rates in Italy and Spain (if we can trust their numbers, which is a big if) would hold for whole populations. We’d then be talking a total death rate currently of 0.04%, maybe climbing up to 0.1% when all is counted.

      Let’s not jump to such conclusions too soon though. This is the sort of number the medics will get right eventually. I would be surprised if there would not already be several papers saying exactly the same.

  24. Hallvor says:

    I’m not a economist or a health expert, but my biggest problem with this analysis is that I don’t see where it takes into account the health systems. Take this as an example:
    https://www.npr.org/sections/coronavirus-live-updates/2020/04/03/826804519/pandemic-claims-doctors-in-the-philippines-at-startling-rates?t=1587479660544

    A lot of the measures were put into place to protect the national health systems from breakdown and destruction. Surely loosing a large amount of qualified health personnel has a cost on top of the life-years directly lost.

    • Hallvor
      My mother was in the mid fifties Matron of Crown St women’s hospital. My wife started her working life in the late seventies as a Theater Nurse. They both were are shocked by the loss of basic anti- septic training in hospitals after about 1990.

      If John Ioannidis is correct then one of the worse things that was done was taking large numbers of moderately ill people into hospitals in the first place.

  25. Jos Gobert says:

    We should get as much knowledge as we can in a real short time now that the pandemic has shown the summit and most of it’s secrets .
    Our specialists should allow their models to be linked on a supercomputer that links the US approach, the Singapore approach, the German approach, Italian, Chinese and Swedish model. It works as a stone of Rosetta. The info for the hierogliefs is there but it has to be decoded in a humble fashion. Today it seems we have so many experts as we have football coaches.
    It will allow us at least that is my conviction, a normal life with handshaking and hugging but not based on our intuition or our political ideas but on the best possible model within boundaries. The individual variety will be there. People told me, a 58 year old GP 4 weeks ago with 38 fever symptoms for 2 weeks, to give it a rest for a month. Today I made a 6 km run pushing frequencies to 178 for a short while, cautiosly. Some will wait a bit longer, some might try earlier. That is the individual variety. But for European society as a whole we should be able to work out a rational best practice. Once this is done we can travel, swim, dine at least within the society that accepts the same rules. Everybody thinks it will be a society with apps and masks.
    But that again is looking at examples from the far East. I’m not convinced but will accept ratio (even though for me, probably immune, it is not even necessary)

  26. Joe S. says:

    Given the nature of how viruses propagate, efforts to “flatten the curve” serve mainly to delay infection and hence delay (but do not prevent) most deaths within the population. Having trouble finding proper analysis of this fact but perhaps 80% to 95% of the final death total is doomed in any event. I would be interested to hear how this might alter the discussion. Also, I would appreciate any insight into how to quantify lives saved through “curve flattening” efforts.

    • Kien Choong says:

      @Joe S. Hi, I think “flattening the curve” simply means stretching out the infections over longer periods, so that the public health system is not overwhelmed and are able to treat patients. Whereas “letting it rip” implies that the health system is overwhelmed, and patients die because of the lack of treatment.

  27. Jos Gobert says:

    I’m not sure about the 80%. Maybe less but 60% at least. (including second and third wave) Now we leave the disease to its’ natural course but try to avoid and delay. Others try to ignore .
    If we could find 60% volunteers (under 50 no co-morbidities) we probably would reduce death toll substantially. Say as a sort of soldiers. But this would be too much ratio. Working together with the virus and leading it where we want it to go.
    Once we were emotionally stable enough to do this, but we have become a pathetic mammal.

  28. John says:

    The best modeling I’ve seen is here. From Marcel Salathé (Harvard/Stanford)
    https://ncase.me/covid-19/

  29. Liesbeth says:

    One important note, which is not in your calculation, is that young people that get affected by the virus, run the risk of permanent lung damage, it for sure takes them months to recuperate from the virus. And these are not necessarly the ones that end up in the hospitals. In the Netherlands more then 50% of patients in the hospitals and 75% of the patients in IC are under 60y old and only few of them have underlying diseases (including obesitas). So if the young (And herewith working population and parents) are infected in such a way, how do you think letting the virus spread will affect economy and daily life? I think therefore your calculation gives a false depiction of the situation at hand.

    • Hi Liesbeth,

      yes, I think this is a fair thing to want to consider in these kinds of calculations. The question is whether this is a small loss relative to the deaths or a large loss. That boils down to how many life-years those younger patients have lost and how many there are of them. My understanding is that there are only a few thousand of them in the Netherlands, whilst millions are affected by unemployment and the misery of social distancing.

      Also, we do know that lungs slowly self-repair and self-regenerate over time. Other diseases also affect organs and lungs. So one should not be overly dramatic about such things but try for a reasonable view of how large this effect is. When I looked at this about two months ago, I put this in the “very small” basket of effects relative to the deaths and other effects of this pandemic. Its an empirical question though and maybe this is much bigger than it seemed previously. Are you willing to give me an estimate of how many thousands of life-years are lost via young people with severe symptoms if, say, 80% of the population below 60 years of age were exposed to the virus in their environment (which would be the case in any long-run scenario if there is no vaccine)?

  30. Liesbeth says:

    I don’t have those figures for you (i am not a medical professional, and I have not seen any estimate yet in the literature), but I did understood that it can lead to permanent lung damage, as this is the case in a young person I know that was affected by covid but not hospitalized). Furthermore lung damage is only one of the possible organ damages done by this virus. I have to look up the literature.

    As to loss of life years I think it would be more fair to change this to reduced Quality of life years, or going economic reduced working years and consequent Increase in uptake social benefits and other costs for society (such as medical costs and other societal costs, such as partners that can work less for they need to take care of the patient and their possible children). Most likely we can only calculate these effects and subsequent costs in hinsight. It is now simply too early to say anything useful on this account. And on the positive side, the lockdown, can lead to a more sustainable and healthier (western) world, with possibly more efficiency in work, by use of working from home more(which will benefit society), less traffic , less producing for export (which will benefit society in health costs, and costly effects on environment), less import (medicine, medical
    appliences) and towards more local economies (which will benefit societal costs on all areas). The only big downsize of this is that it can lead to technocracy which will reduce democracy and government control. I think these two things are the ones we should be critically following.

    • Hi Liesbeth,

      I dont think you need to be a medical professional to have a go at those calculations, as long as one can read the medical literature. There is a whole century of literature available and there is bound to be many studied cases of the long-term effects of various forms of lung damage. Of course every disease has its unique characteristics, but one can make reasoned estimates. Lungs have been damaged by smoking, bullets, knifes, pneumonia, pollution, poisons, etc., and all of that has probably been extensively analysed for long-term consequences, a literature one can interrogate in terms of similarities. Probably better if one is not a medic when making such calculations as one then does not have to please other medics by coming up with some highly inflated number.

      Your other point on possible benefits of the lock downs is of course also relevant, but there I strongly disagree with most of your arguments, though am happy to see evidence in the other direction. On pollution, I’d point out there is a lot more transport of goods now happening to people’s doors that compensates quite a bit for the reduced commutes. Also, I dont think remote working is sustainable as there was a deep reason we had all those expensive offices and commutes to the offices: people need to be in close proximity to be a working group. Without close proximity, the loyalty underlying them falls apart. I hence dont think one can maintain large corporations and businesses without physical places where people are close together, particularly not professional teams and head offices. I say that as someone who has written a book on loyalty, groups and identity so its not a recently invented argument on my part. However, there too I am happy to change my mind if it turns out different to what I expect. But I dont currently think home working is sustainable. Indeed, I think people will eventually migrate to places that are more relaxed if their governments would truly force them to “stay at home”. They want to be in physical proximity to others. Similarly, I think it is very unhealthy not to touch many others and to be touched by many others, a form of sterility that will lead to many more diseases and weaknesses emerging.

      But these are exactly the kinds of arguments people should be having. However, there is a real danger in people simply coming up with more and more reasons to justify the situation that has emerged, an ex post rationalisation that merely hides the fact they like the lock downs for some reason they are not admitting. If they are really wondering what the costs and benefits are, they should make an effort to try to generate reasonable estimates of all the main positive and negative things they can think of.

      I have just explored that very question of ex-post justifications in my most recent blog: https://clubtroppo.com.au/2020/06/17/what-kind-of-crowd-are-we-now-seeing-the-5-surprises-in-this-pandemic/

      • John says:

        Further studies on long-term impact of CV19. Suggesting that many experience debilitating symptoms, and may take years to recover, if ever.

        Blood clotting, stroke, embolisms, heart damage, lung damage, neurological, etc.

        https://www.advisory.com/daily-briefing/2020/06/02/covid-health-effects

        https://www.theatlantic.com/health/archive/2020/06/covid-19-coronavirus-longterm-symptoms-months/612679/

        https://www.healthline.com/health-news/what-we-know-about-the-long-term-effects-of-covid-19

        • Hi John,

          yes, I knew of these in a rough sense, but thanks for the links.

          Same question to you as to Liesbeth: are you game for putting this into an estimate of life-years lost (preferably in WELLBY terms as physicaly health is only basically 1/3 of the WELLBY, recognising that people care about a lot more than just their physical health, which is the big problem with the QALY)? Particularly important, I think, is a reasonable estimate of life-years lost via this avenue if some 80% of the population were somewhat exposed to the virus?.

          I ask for that specific counter-factual because I think that that kind of herd-immunity level of exposure is the most relevant case which most Western countries are going to end up with unless they remain in a highly costly suppression mode till a very effective vaccine is found, which would be a miracle if its this year and still highly unlikely before the end of next year. Given the enormous health and social costs of the repression, I dont think many countries are going to be willing to do that and will hence, roughly speaking, get the damage involved in the 80% scenario.

          oh, and btw, it is of course quite possible that something like 80% has already been exposed, but that our serology tests (which pick up the highly-infected) simply dont pick up those other-exposed, for instance because of some degree of previous immunity from a previous related disease.

          • John says:

            Ultimately it’s a moral question. Not unlike the abortion debate, except CV19 has a strong economic component. It’s also a question begging for data, i.e., how long before a vaccine? How long does (herd) immunity last? What are the economic consequences of long-term health debilitation? Those questions are fundamental to, and inextricable from, the moral debate.

            HIV has been circulating in the human population for 100 years, and we still don’t have a vaccine, and it’s killed 40M souls, with perhaps another 20-30M currently suffering with HIV-sickness.

            Perhaps we will never see a CV19 vaccine. If that’s the case, or even if it’s delayed 3-5 years, then the arguments become clearer. If the vaccine is available in 6-12 months, then we have grounds for a different argument.

            We simply don’t know yet.

            So there’s very little moral or scientific certainty in anyone’s argument, it’s all based on some very big bets of foresight. Personally, based on my reading of coronavirus histories, I don’t think a viable vaccine will be available for at least 3 years, if ever.

            With that in mind, I (personally) would chose the fastest route to herd immunity — without overwhelming regional medical facilities — and hope that immunity persists for at least 2 years.

            Ultimately, in any CV19 argument, it always comes back to maintaining a viable medical infrastructure. If we allow infections to decimate a medical system, the economic and social consequences become far worse than any sort of SIP mitigations.

            • Conrad says:

              If you’re going for herd immunity, I don’t see any reason why you need to get it as fast as possible and nor would you be able to get it quickly. The assumption is people won’t try and avoid it at the individual and at the group level (e.g., teacher strikes etc.), which they will, and that will make things slower. Similarly, the more people get it, obviously the slower it simply be to get.

              In addition, since it would take perhaps 3 years to get herd immunity, vaccines coming out in that time would still be favourable. So to me this a probability game. For example, what’s the probability you lose all immunity after a few years (doesn’t seem that likely to me), what’s the probability you will get a vaccine in a few years etc.? There’s some relate commentary on this in today’s issue of science (https://science.sciencemag.org/content/368/6497/1295?utm_campaign=toc_sci-mag_2020-06-18&et_rid=79427868&et_cid=3370910)

              I worry about the neurological damage too, although I think I value it more highly than other people. If we really cared, we’d be worried about sports played widely like rugby and AFL where people are not knocking their brains out commonly enough. But no-one cares about them. Similarly, there’s good evidence that poverty has long term effects on intelligence and no-one cares about that either. So we don’t care that much.

  31. Paul
    Because of the number of posts you’re done on Covid19 and the number of , continuing, interesting comments across many of those posts , it’s becoming hard to follow them all.
    Below is a link to,
    The economists summing of theUK viz Covid19 https://www.economist.com/leaders/2020/06/18/britain-has-the-wrong-government-for-the-covid-crisis

    Personally I thought that Sweden and the UK would come out roughly much the same re per capita deaths.

    • paul frijters says:

      Hi John,

      yes, there have been many developments I have kept track of and commented on via this blog. Its an evolving perspective on many fronts, all in the context of a continuous stream of new information and evolving beliefs of others. I can imagine its a bit overwhelming. Yet, it all seems clear in my own head :-)

      • Kien Choong says:

        Ha ha, I’m afraid I lost track of the details quite a while ago.

        It would be nice if one day, you and someone like John Quiggin or Simon Wren-Lewis could write complementary pieces identifying points of agreement vs disagreement. I think it would be very helpful in our response to the next crisis.

  32. Pingback: The wellbeing costs of physical distancing - What Works Wellbeing

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