In just 18 pages, the paper highlights the searing choices facing all governments, especially the choice described by Sakib Sherani in a recent article as “impossible and Hobbesian…the “forced” trade-off between lives and livelihoods.”
The paper begins with the results of a recent study led by Professor Barro that extrapolated from data from across 48 countries to estimate that the 1918 pandemic killed around 40 million people worldwide. Estimates from past studies have ranged from 17 million to 50 million. This fairly specific estimate is closer to the 50 million than to the lower ones, and as Professor Barro adds, 40 million people amounted to 2.1 percent of the world’s population 100 years ago; the same percentage would correspond to 150 million people today.
Professor Barro concludes that the mitigation policies of US cities in the Fall of 1918 flattened the curve of infection but failed to reduce the death rate significantly because they were not in place long enough. Looking at over 40 cities in the US, the study uses their three non-pharmaceutical interventions (NPIs), common to those used 102 years later, and now against COVID-19, to judge whether they mitigated the death rate of those cities.
Public experts agree almost unanimously that we are not ready for a sudden wide “opening up”
These NPIs were used against the second wave of the Pandemic, which came to the US in July or August 1918 from Europe. If it seems parochial to study only American cities, the reason is that the data necessary is not available from the rest of the world. The three NPIs Barro uses to judge whether cities were able to reduce the infection and, more importantly the death rate: school closings, prohibiting public gatherings, and quarantine/isolation, by which he means what we are calling social distancing. The answer is that they often flattened the curve of infection rates but had very little impact on the death rates. The lesson, he writes, is that for our present Pandemic NPIs, “to curtail overall deaths…[they] have to be maintained for substantially longer than a few weeks.” “Most likely,” he says, “12 weeks work much better than 4-6 weeks.”
In the US, these three NPIs have been in effect barely five weeks in the earliest cases and for shorter periods in most states. And some of our states—the more rural and agricultural ones — have not felt the need to implement them at all. Only one state, California, implemented the three NPIs earlier than six weeks before this article is being written, doing so on March 19. As our most populous, and the leading economic power among the states, it has played an important role. Community spread of Coronavirus, meaning someone with COVID-19 who had no contact with other known carriers, was discovered in the San Francisco region in late February. This led the State to implement the three NPIs to prevent a more rapid spread and ensure that public health facilities, especially hospitals would not be overrun.
The San Francisco region adopted NPIs even earlier, and it shows in the very flat curve of infections, and it seems possible that the death rate will also be lowered, but I think it too soon to make that conclusion. The majority of states, 33 by my rough count, followed along and issued stay-at-home orders or “recommendations” before the end of March, although these varied in their coverage and enforcement. Ten states followed in early April, but seven states have refused to adopt NPIs at all. The Trump administration has been unhelpful by displaying no enthusiasm in the early weeks of the pandemic, finally putting out NPI guidelines after most states had already implemented them.
The issue of whether to remain nestled in our social distancing cocoons or to begin to open up our society by allowing some, if not all, businesses to reopen, some if not all gatherings (sports events, theatre productions and concerts, etc) to take place is a very neuralgic one in the US these days. Which do we value more as a society, the lives that might be saved by keeping these NPIs in their entirety in effect, or restoring some economic dynamism and a return to our livelihoods as we knew them before COVID-19 knocked us all out of the box. This is not an easy question, and there are complications that make it almost impossible to solve. As Sakib Sherani points out, the simple trade-off between lives and livelihoods is a false choice; as we don’t know and can only guess whether “opening up” the economy will lead to a recrudescence of COVID-19 that would again threaten to overwhelm our health care system and put paid to the desired economic resurgence we hope for. Does a fully functioning economy depend on a normally functioning public health situation, or would it operate as we hope with a community health crisis raging around us? And when and how can we relax the NPIs in ways that will begin to rebuild our livelihoods without a major spike in the COVID-19 infections, in the death rates and in the assault on our health care system?
Professor Barro’s study does not answer this question because it cannot. It will be up to our political leaders to answer those questions. And that is the problem as they have become intertwined with political ideological differences and dogma. The point of NPIs is to flatten the curve of infections so our health care systems won’t be overwhelmed the way that many were in 1918, and for the most part, where they have been implemented they seem to have succeeded—handsomely in the case of California, barely in the case of New York, and middling well in most other cases. Healthcare systems like that in Louisiana that looked for a week or so to be on the point of collapse, have succeeded in overcoming the crisis in beds, ICU beds, ventilators, protective equipment, and infected health care workers, and now are on the downslope of the spike in infections, though not so much in deaths yet. But public experts agree almost unanimously that we are not ready for a sudden wide “opening up.” What is seriously missing in the US is the testing and contact tracing that has allowed the successful Asian countries, South Korea, Singapore, New Zealand, and others to open up almost fully. Testing has been deficient in the US since the beginning of the crisis and the Federal government is mainly responsible. How we can get enough testing to begin to open up carefully is unclear as the administration seems to have abandoned its responsibility and to be leaving that to the States. There are governors who are resisting moving too fast, but others who are pushing ahead at a full head of steam, testing be damned. And there are those governors who have not implemented NPIs and whose states have seemed to escape, so far, the COVID-19 infestation, and may still be on the verge of crisis. Opening up has become a partisan crisis, with Trump and his supporters pushing hard for more speed, and Democratic leaders sound cautious notes and insisting on widespread testing.
The New York Times has reported tonight that the Center for Disease Control (CDC) is projecting a sharp rise in the US infection and death rate in the next few months. As I understand it, this is based on the swift rise of infections in the south and the middle of the country, primarily in states that are now leading the way in opening up, primarily states that have favoured President Trump. The president, in the meantime, seems to have given up on getting ahead of the situation and to be concentrating on his re-election.
The writer is a diplomat and is Senior Policy Scholar at the Woodrow Wilson International Center for Scholars in Washington, D.C.