The coronavirus crisis is terrifying not just for its potentially staggering scale, but also for its resistance to rational analysis. It’s forcing governments to make enormously consequential decisions without knowing what the results will be or how alternative courses of action might have played out.
This state of affairs is so unsettling to the rational mind that one longs for rules of thumb that suspend doubt, set complications and trade-offs aside, and offer some clarity. “Just do everything, and worry later about having overreacted” seems to be trending. It sounds reassuring and purposeful, but only so long as you don’t think about it too much.
With millions of lives and colossal economic losses on the line, COVID-19 is still in the realm of radical uncertainty. At the moment, there’s too little information even to calculate usable probabilities. At some point there’ll be more clarity about actual cases (as opposed to reported cases), transmission in different populations and under different policy regimes and other conditions, true fatality rates, infectious periods, acquired immunity and so on – enough to better understand the pandemic’s processes and the pros and cons of different interventions. But knowing all that later is no use now. And one thing we do know: “Wait and see” is not an option.
Amid this extreme uncertainty, a crucial trade-off persists – between the steps you take now to save lives and the damage those steps will do to the economy. At first sight, in the spirit of “just do everything,” one longs to deny this trade-off: Governments should move instantly to save as many lives as possible, while reducing the economic damage as far as they can. This thinking sustains the view that hesitating to adopt “lockdowns” in many Western countries – the initial preference for “mitigation” over “suppression” – was a grave mistake. The truth is more complicated.
An unacknowledged trade-off between saving lives and inflicting economic harm is simply unavoidable. It’s baked into the way we live our ordinary lives. Seasonal flu kills (or contributes to killing) tens of thousands a year in the US. There are no calls for “lockdown” at the first sign of a seasonal spike. Partially effective vaccinations are available: So relaxed are we about this preventable loss of life that we don’t even accept the public cost of making vaccination free, much less mandatory.
The threat from COVID-19 is of a radically different order, and the terms of the trade-off, once they can be calibrated, will be very different as well. But policy makers still need to strike balances, recognizing (whether they like it or not) that the underlying dilemma of safety and cost hasn’t gone away.
You can see this in the ambiguity surrounding “lockdown.” People in the US and Europe are being urged or compelled to stay at home except to undertake essential activities. But what’s essential? Governments aren’t sure. They’re using the term without knowing what it means. (At the start of this week, for instance, UK policy makers were unsure whether their stay-at-home order applied to construction workers.) The ambiguity arises precisely because the underlying trade-off won’t go away. It means there’s no bright line: The extent to which shutting things down puts firms out of business and people out of work tells you what’s “essential.”
In a similar way, under current conditions, there’s no bright line in policy terms between two approaches to the pandemic that are sometimes contrasted as if they were clearly distinct – “mitigation” and “suppression.”
In epidemiological terms, you achieve suppression when each infected person, on average, passes the disease to less than one other person. Reduce person-to-person contact enough to do that, and the epidemic comes to an end. To an epidemiologist, mitigation means spreading out the cases to reduce the burden on health systems unprepared for a surge, but without aiming to halt the epidemic before it eventually runs out of people to infect.
As a practical matter, the distinction is much less clear-cut. Scientists aren’t yet sure of the coronavirus starting point – the number of people that each infected person would infect in an entirely susceptible population. This so-called basic reproduction number seems to be between 2 and 3, which encompasses a wide range of future scenarios even before you weigh the many other unknowns. And policy makers also don’t know how far each successive tightening of the rules on social distancing, running all the way from urging to people not to mix in big social gatherings to criminalizing all “inessential” contact, might succeed in reducing secondary infections.
So the policy choice is not between a clearly defined (a) and (b) – between mitigation and suppression. In practice, governments have to choose a point on a continuous spectrum of escalating restrictions, not yet knowing how these restrictions will affect transmissibility, how long they can be sustained, or at what point (if ever) suppression would be achieved, all while knowing that each additional step risks further crippling the economy.
Better to acknowledge these uncertainties than pretend they don’t exist. Recognizing them doesn’t mean paralysis, but it does argue for a degree of humility – including when it comes to criticizing governments for their initial reluctance to severely restrict person-to-person contacts.
Outright mistakes have certainly been made, but mostly before the pandemic even began. This emergency was a foreseeable event. Governments had appeared to devote thought and effort to preparedness – and yet the West’s systems were all but entirely unprepared. Health systems lacked stockpiles of essential basic equipment. Hospitals had very limited surge capacity, and in most cases, it seems, governments had no plans for developing such capacity at short notice. Lack of preparedness continues to confound smart choices about how best to respond. It imposes limits on testing for the virus, for instance, obscuring the nature of the enemy and ruling out other desirable interventions, such as strictly isolating carriers before they can infect others.
For the moment, severe restrictions on personal contact, maximum effort to build testing and surge capacity in health systems, and unsparing economic support for the firms and workers shut down by government edict might be the best we can do. If, in the end, this means mitigation rather than suppression, it will at least have bought some time to build health-system capacity and, one hopes, develop the knowledge necessary to treat and prevent the disease.
But, much as we might want to ignore it, the underlying trade-off between fighting the disease and crushing the economy can’t be denied. Whether we admit it or not, it’s already dictating events.
Bloomberg
