Spending Social Good Will

I'm not convinced that the current efforts at combating the spread of COVID-19 are a wise course of action. I realize this statement is currently outside the Overton window for polite society. In the past I've advised people who are skeptical to at least try to make the experiment work. At this point I'm recommending that ...

...well, that you not look to random bloggers for advice on this kind of thing. However, if you're looking for a bit more understanding that's something I can supply. I know this is a contentious issue, so I'd like to start on what I think we can all consider to be common ground, given the state of the evidence to date.

Firstly, the defining nature of this crisis - and the beginning of any pandemic for that matter - is uncertainty. Back in early March, I noted this fact, and that some things we would likely discover over time and other things we might never know. Some of the things I noted back then turned out to be incorrect, as is expected given this level of uncertainty. Some look like they've aged better.

The point is that everyone - even the experts - is faced with a large amount of uncertainty about the nature of the problem and what might happen in the near future. When the decisions were first being made to ban travel and then close everything down the biggest uncertainties surrounded the rate of transmission and the rate at which people who get the virus would eventually die from it, with some additional uncertainty about how much the virus would drive increased hospitalization. That first week in March, it looked like the death rate due to the disease was probably around 0.5%, but estimates varied with a range upwards of 5% or even a little higher. Given that uncertainty, and the possible range we were working from, it made sense to shut everything down. Better safe than 1 in 20 people dead.

Second, I know a lot of people are doubting whether hospitals were ever truly hit with large numbers of patients. I see some people claim it was all a hoax, then other people - ironically - claiming to be 'a nurse from wherever'sville' who was called up to the Big City to pile up the bodies, and she has seen the bodies, and it's horrific! (Hint: don't claim to be a nurse from X and list yourself as a high school teacher from Y on your public profile. Also, don't make up a hoax to 'disprove' that this is all a hoax. You're not helping.) I have not personally witnessed the overcrowding, but I find it credible. This is because I work directly with physicians in my job. I know multiple physicians who confirmed the crowding - especially in the New York area, but in other areas as well.

Finally, I think the evidence strongly supports the hypothesis that the quarantine is saving lives. Two weeks ago, I discussed the case of Sweden versus other Nordic countries. Although I'm not convinced they're still on track to post an order of magnitude more deaths than their neighbors, I think it's still clear they'll see more fatality than Finland, Norway, and Denmark. Possibly combined. This is an important point for supporters of the quarantine to understand. I know early on that unscientific graph about 'flattening the curve' made the rounds on the internet and became part of the conversation; it was always a possibility that the chart might represent the course of the disease, but that doesn't look likely at this point. Instead the evidence supports a new model where the curve shrinks, but does not get longer. Of course, it's still possible we get another wave if there are a lot of susceptible people still milling about, but that's a different prospective scenario.

Given all of the above, how could I possibly believe the current course of action is misguided?

Let's talk about the antibody data for a second. A recent survey of the New York area (not the entire state, but Manhattan and Long Island - the places hit hardest) showed 21-25% positive antibody testing. This means a lot of people got COVID-19, recovered from it, and never got added to the official case number accounting. If we add them in and recalculate the death rate it should go a lot lower, because now we're dividing the same number of deaths across a much larger denominator. That would put the true mortality rate of COVID-19 far lower than the worst estimates, and in line with the original half a percent estimate. There's some concern at the moment about false positives, which could be pushing those numbers up and therefore the true death rate might appear lower than it actually is.

However, the converse of this is that an antibody test looks for antibodies, not COVID-19. If you were infected today and got the virus, you'd show up negative on the antibody test if you did it tomorrow. In fact you'd continue to show up negative until about two weeks later when your body finally has antibodies against the virus. So the appropriate comparison for antibody tests done last week and reported on Monday is not the death rate as of Monday. That comparison will vastly overstate the death rate, since half the people who had been exposed to the virus on Monday didn't have it two weeks before then, which is the latest date we can successfully test for recovery. Maybe we need to do another study where we do both the real-time PCR testing and the antibody testing at the same time.

Let's do a rough estimate of how those two considerations might play out. Let's say the test has a false positive rate of 50%, meaning every time we do a test and get a positive result there's only a 50% probability it's accurate. That would reduce the denominator to around 10% of the population actually having antibodies and with the reduced denominator increase the death rate to around 1%. Meanwhile, the number of deaths doubled in the intervening two weeks, so we should adjust the numbers down again and we get back to the same 0.5% death rate.

What we were waiting for back in early March was better data. We made decisions based on uncertainty about a wide confidence interval that included truly horrific disaster scenarios. Those decisions weren't made based on realized dangers; they were based on risk that were possible based on the unknowns we were facing at the time. But we have better data now. The confidence intervals have shrunk, and no longer include estimates even close to 5%. As such, the cost-benefit calculation should change dramatically.

Credibility

Do you remember the last pandemic? Nearly every reader of this blog should easily be able to. It was way back in 2019. It is common enough that we don't call it a pandemic, but rather a 'flu season'. It's not really something we think about, but epidemiologists study its complexities every year. We don't think about it as a pandemic that kills lots of people every year because it's commonplace. How common are things like COVID-19? Lots of people are saying it's a once a century - or more! - kind of thing. But at a death rate at or below 0.5% is it possible we've experienced this kind of thing a lot more frequently and just haven't seen it before?

The test we use to identify COVID-19 isn't new compared to the latest iPhone, but it is new compared to the idea of an iPhone. I remember back in 2007 - when the iPhone first came out - real-time PCR was still an expensive and seldom-used technology. Rapid sequencing was in its infancy, compared to today. In other words, we're much more capable of identifying something like SARS, MERS, or a dozen other illnesses we would previously have considered just a bad flu season.

Epidemiologists have been warning us for years that the next disastrous pandemic could happen at any time. This is why they track these things so closely, so they can get on top of them before they strike. COVID-19 was not the pandemic they've been warning us of. It's maybe a little worse than a bad flu season. A truly horrific pandemic is coming sometime down the road. We don't know when. And although the current experiment is promising, in that we were clearly able to reduce the spread of a particularly fast-spreading virus, it's also worrying.

Unless we seriously reconsider our intervention in the face of new evidence - and soon - the public may not respond well during the next pandemic. The boy who cried wolf got three chances before nobody heard his cries. The public likely won't give as many. Epidemiologists made an understandable call when they advised shutting everything down two months ago. I think I would probably have made a similar call - even though I was never convinced the death rate was likely as high as 5%. The possibility of 5% still existed back then, and I think isolation was probably the most rational call given the evidence available. Today that hypothesis should be rejected. The high end of the confidence interval is much lower, and as such the only understandable call is to reverse course.

This change will likely lead to more deaths than staying the course, as we saw from the Nordic data. But that's the hard price we must be willing to pay. As it is, we experienced two difficult months and people got upset, but if we open up for the summer most people will move on. Then for the next pandemic - possibly The Big One epidemiologists have been fearing - we'll know the social distancing works and (hopefully) people will be willing to comply for a bit as we learn what's going on. Maybe we'll even implement a few things we should have done and be more prepared. We could come out of COVID-19 stronger and more prepared for the real threat.

If we don't loosen things up, knowing what we know now, we risk a greater problem in the next pandemic. People will assume governments are just overly cautious. That there's nothing to fear from this kind of thing. And - crucially - that the next pandemic will behave similar to how the last one did (in route of transmission, death rate, and in the population that's vulnerable). They'll be wrong, and the deaths will soar.

Yes, continued social distancing will save lives, but at what cost? When we implement policies like this one, we're spending a different kind of capital than just dollars and cents. We're spending public good will. So far, the public has been hugely supportive - more so than I thought possible at the outset of this experiment. But that support won't last forever. It has already waned for some groups. The ranks of the disillusioned will only grow the longer we keep this up. And, if we keep it up for too long, we may find we don't have enough social good will left when a particularly bad pandemic hits. Because we spent it already.

Comments

  1. So your major concern is not the impact to the economy, but the impact on people's willingness to do this again should we have another pandemic? Interesting.

    I assume this means that regardless of how long the current "lockdown" lasts, that you're definitely not in favor of doing any more should there be additional waves?

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    1. The decision to implement the current 'lockdown' measures was made under a different level of uncertainty about the potential harms COVID-19 might bring. We didn't make the choice we did based on known harms, but on potential harms. This was a coronavirus similar to SARS and MERS, each of which had death rates well over 5%, so it was possible this was a 'milder version of SARS' with 'only' a death rate of 5%, which would have been horrific. Given the unknowns at time, the right call was a shutdown.

      Let's say back in late February we knew everything we now know. Would it be wise to implement a highly costly policy such as this one given a death rate at or below 0.5%, or maybe even up to 0.7%?

      No. I submit we wouldn't have pursued such a policy at that time, and the only thing carrying forward the current policy is the social stigma of first movers and the proven increase in deaths the policy change will lead to. The problem is that the public - and even officials - are bad at sunk cost analysis. The shutdown has to mean something, and in this case it has to mean saving lives. But we'd never do this kind of thing for the annual flu season, because it doesn't make sense economically and people would eventually balk and stop going along with it. Knowing what we know now, we should make decisions that make sense now. I think the public would respect that much more than stubbornly staying the course no matter what.

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    2. Hmm... I'm not sure that I agree that if politicians had had all the data we now have that they would have avoided all shut-downs. For example look at New York, it's hard to argue that New York would have done better without a shutdown, are you saying that what happened in New York would not have been convincing?

      Now arguing over what the politicians would have done is different than arguing about what they should have done. But I see being blamed for the killing of old people as having quite a bit of weight in the calculations of most politicians.

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    3. Back in late February we were getting reports from China that the hardest hit population was the Elderly. We also saw the large smoking population in China was having difficulties, which wasn't a surprise, given SARS-CoV-2 mainly attacks cells in the lower respiratory tract. However, that was entirely preliminary at the time. We didn't know if non-Chinese populations would react differently, or if other risk factors might become particularly problematic. Because the US population is significantly different from the Chinese population there were a lot of unknowns.

      I think now we have a much better understanding of which demographics are getting the worst of it. Even in New York, with all they saw, a much more rational strategy would be to isolate/'cocoon' vulnerable populations, as opposed to shutting down the whole city.

      As to what a politician would do, you have two constituencies you have to appease: the vulnerable - especially the elderly - and people who want to get back to work. Given that mortality rates for COVID-19 don't really start to get worrying until around 65, it's intriguing that these two populations are almost entirely mutually exclusive. You could insist on indefinite shutdowns, but that foments reactionary movements, and at the very least costs you a lot of votes. You could open everything back up, but as you mentioned you'd get blamed for killing old people.

      So the only viable political option at this point (having enacted shutdowns) is to 'slowly' reopen most things, while keeping strong measures in place to protect vulnerable populations. You do it slowly, so it doesn't look like you're recklessly experimenting on the population, and all the while you push PSAs about how we need to keep old people safe.

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