Thoughts on Covid, pt 2: responding to crisis
The opinionist in me is fascinated by how various leaders responded to the Covid crisis, and I asked myself what might I have done.
See part 1 here. Below are some long-form thoughts on the evolving Covid crisis; these views do not represent anyone other than my own.
I like to start any Covid discussion by (a) thanking all crisis-agnostic workers who put themselves in various frontline roles for the public benefit of others (e.g. healthcare, post office, public transit, etc. workers) and (b) extending sincere sympathy to everyone lost or will lose a loved one or cherished experience due to Covid.
Global responses to Covid
What do a trauma surgeon, combat officer, and NFL referee have in common? The terrifying ability to remain stoic while triaging high stakes decisions mid-crisis. An empathetic version of that skill is expected of a President during a national crisis. Someone could make a great peacetime leader and yet a useless wartime leader.
With the benefit of hindsight, it’s interesting to revisit the spectrum of how different world leaders handled Covid:
- Track-and-trace — South Korea: After experiences with SARS in 2002–03 and MERS in 2015, SK had built up its diagnostic testing capabilities. With Covid, President Moon Jae-in took a big data approach to contact tracing, using credit card history and location data from cell phone carriers to retrace the movements of infected people, a tactic most South Koreans supported despite sacrificing digital privacy. (NG, CNN)
- Herd immunity — Sweden: Premier Stefan Löfven chose to play the long game, preferring a response that he promoted as being more viable over time. Löfven banned large gatherings and closed high schools and universities, as well as recommended social distancing, protecting the elderly, working from home, and staying at home if unwell. (Reuters)
- Economic mobilization — Germany: Chancellor Angela Merkel was very disciplined and analytical. Germany, with a public health care system and social democrats in power, has a lot of government control over coordinating health and economic responses. Merkel mobilized huge amounts of testing, locked down the country, and pumped an enormous amount of money into the economy (i.e. 60% of GDP vs. 20% in the UK or 12% in the US, as of April 20th CNBC). Germany has been one of the first European countries to re-open.
- Lockdown — UK: Prime Minister Boris Johnson took the herd immunity route until a non-peer-reviewed article measured a 0.4–1.4% mortality rate (ICL) and triggered a shift in strategy such that Johnson swiftly shut down the economy (NYT), even as conflicting research articles were emerging (e.g. BBC or FT).
- Patchwork lockdown— US/NY: President Trump and Governor Cuomo appeared to play every side of the debate at various times (WSJ). Overall, Trump delegated to governors to implement state-level responses while the feds focused on resource mobilization and stimulus packages. In NYC, Mayor De Blasio seemed to want to keep the city open (the head of NYC’s public hospital system at the time said that there was “no proof that closures will help stop the spread”, NYT), but then Cuomo took the state into lockdown.
The jury is still out (as my Swedish coworkers like to say) on the holistic efficacy of various policies, and it will probably take years to collect enough data to understand the true impacts and externalities. Interestingly, approval ratings for national leaders have increased across the board (incl. Sweden, Germany, Italy, China, the UK, etc.), except in the US where we follow the mantra of “local good, central bad” (538).
Michelle’s US response to Covid
As Teddy Roosevelt said, “It is not the critic who counts…The credit belongs to the [wo]man who is actually in the arena.” In the spirit of going beyond being an ‘armchair critic’, I challenged myself by asking: What would Michelle do (WWMD)? It’s mid-March and there’s growing international and domestic fear about the virus. We don’t have adequate testing to paint a clear picture of cases or fatality, and the US is not fully prepared to combat a pandemic (per GHS; notably, we ranked 1st overall but 175th of 195 countries in “healthcare access”, 59th in “socio-economic resistance”, and 117th in “environmental risks” e.g. urbanization). We’ve overspent on endless wars and undersaved on collecting taxes, and federal debt is at an all-time high (NPR). In lieu of a playbook, we need a Covid response that is based on a clear and coordinated process informed by science, limited resources, and holistic wellness.
Info ingestion
This is a broad-strokes summary of what the emerging information about the virus was at the time in mid-March (and which is now outdated), but from a policy perspective, I personally would oversimplify it to:
- Covid is a new virus strain that “early estimates suggest is less deadly than the related illnesses SARS or MERS, but more infectious than seasonal influenza”. (Nature)
- Covid is “believed to be the cause of the majority of deaths associated with it, not other factors”. However, “roughly 90% of the deceased have pre-existing illnesses that put them at heightened risk of death anyway”. (ONS, BBC)
- Models predicted that if we took no precautions and if hospital capacity was not expanded, many communities would not be prepared to care for Covid patients. (HGHI)
- We do not have a Covid vaccine or therapeutic treatment, and do not expect to have one in the immediate future. There are currently “no targeted, specialized treatments for Covid, so when doctors detect a Covid infection they aim to treat the symptoms as they arise” (e.g. with ventilators). (WHO)
Info processing
Firstly, I would gauge the level of direct health threat from the virus (first two bullets). Part of this is an issue of ethics (which, if I had an ethics counsel like Germany, I could consult them on) but a health risk that largely accelerates end-of-life for elderly people with multiple comorbidities is much less concerning than something that, for example, kills healthy children; this view is generally substantiated by quality-adjusted life-year (QALY) models used for health economics (CDC). It’s hard to quantify this statement, but I would perceive the disease itself to be a material but not a severe threat.
Secondly, I would gauge our ability to react (second two bullets). We were projected to lack, to some degree, the tools to treat and the capacity to care. How much control do we have over those tools and capacity? There are ways to expedite vaccine development and expand hospital capacity (NEJM), but there are also dangerous trade-offs to approving vaccines too quickly (it “has the potential to cause harm, not only for COVID-19 prevention efforts and vaccine recipients, but also for public trust in vaccination efforts worldwide”, JAMA) and of redirecting hospital resources away from other diseases (of which we are capable of treating and saving lives), and overall my willingness to risk those trade-offs for the sake of a Covid response is material but not severe.
Response
What did WHO suggest we do? The broad recommendations to world leaders on March 11th when they reclassified Covid from an epidemic to a pandemic (WHO) were: (1) Activate and scale up your emergency response mechanisms; (2) Communicate with your people about the risks and how they can protect themselves; (3) Find, isolate, test and treat every case and trace every contact; (4) Ready your hospitals; and (5) Protect and train your health workers.
I interpret this as a mobilization of resources. Using WHO’s framework, my ‘plan’ would look like:
- Emergency response mechanisms — Evoke national resources (e.g. Defense Production Act) to manufacture health equipment, scale-up relevant federal agencies, guarantee small business loans for overhead costs, subsidize childcare for essential workers, and grossly expand Medicare and unemployment to those impacted.
- Communicate and protect — Identify which populations are at heightened risk and double-down protection of them, including targeted social distancing guidelines (e.g. JAMA), mandated paid health leave, supplied medical-grade PPE, staffed community resource centers (e.g. in dense neighborhoods with high rates of comorbidities), and subsidized nutrition & hoteling services. Extend those protections to frontline workers with high indoor exposure (e.g. grocery clerks) and to socioeconomic groups with traditionally inhibited access to care (Pressley). For the low-risk population, encourage healthy, preventative habits like exercise, sunshine, and hydration. Keep schools and businesses open but advise on precautions (e.g. open windows for increased outside airflow) and encourage those who can to work from home. In urban areas, close select streets to vehicle traffic and allow shops and restaurants to bleed onto the sidewalks; for other businesses that demand closed, indoor settings (e.g. museums and concerts), reduce capacity and limit maximum group sizes.
- Track and trace — Mobilize the private sector and expedite regulatory hurdles (JAMA) to develop accurate assays, deploy representative testing, de-compartmentalize healthcare data siloes, and trace positive results.
- Ready hospitals — Temporarily merge the public/private health systems into a single operating system to coordinate patient care, supplement hospital bed space, and expand existing capacity.
- Health workers — Mobilize an expanded public health workforce (e.g. via medical school students, per the editor in chief of JAMA), and extend at-risk protections to healthcare workers.
And what if that’s not enough? What if the hospitals become overrun and healthcare workers are making decisions about who receives what level of care. Unfortunately but thankfully, we’re prepared for this, because medicine has ethics guidelines on allocating limited resources (Freakonomics had a good overview). Rationing is a not-uncommon reality of medicine which we’ve experienced in the extreme (e.g. insulin for diabetes, penicillin for bacterial infections, and long-term chronic dialysis for kidney failure) and in seemingly less acute ways (e.g. organ donations, hospital wait times, restricted access to insurance, etc.). It’s not about being heartless or turning a blind eye to the problem, but about accepting a certain level of risk given competing demand for limited resources.
On the question of lockdown
Can we function as a society without a vaccine and/or therapeutic treatment? Early on there were some extreme views that we would be in lockdown until a vaccine became available, but that perspective lost traction (NYT) even though we still had “no idea” how to treat Covid and did “not have good estimates for where we [were] on the epidemic curve in different places” (Harvard).
I personally don’t believe that shelter-in-place policies were ever the best policy response for Covid. Lockdown seemed like a decisive and necessary move in mid-March, but to me, it was reckless and misguided; we had no plan so we acted like a lockdown was our plan. But a universal shelter-in-place is either (a) prohibitively expensive to counter with a true social safety net plus requires effective means of deploying financial aid quickly or (b) does not provide adequate benefits to the target beneficiaries. The US is not equipped to mitigate (a), perhaps best displayed by the Small Business Administration PPP loans debacle (NPR) where the SBA was at times handling 50x what they normally process in a year (SBA, WSJ), and we seem to be experiencing (b), with major Covid hotspots at nursing homes (USAT) and in at-risk communities (NYT).
My interpretation was that the lockdown hysteria escalated politically because a Republican President was downplaying the crisis and shirking responsibility, and so high-profile Democratic governors took a counter position; “the US has yet to implement an effective disease control strategy” and instead were left with “a single approach — social distancing” (JAMA), so a lockdown was the boldest statement.
To me, issuing broad lockdown orders was like jumping into a black box. Do we know what that does to the economy? (GDP, inequality, unemployment, bankruptcies, national debt, etc.) Or to public health? (Depression, substance abuse, fitness levels, nutrition, obesity, cardiovascular disease, etc.) Or to child development? (Access to education, social development, abuse, neglect, etc.) Or to the social fabric of society? If shelter-in-place was the chosen response policy, then there should be known parameters that justified the lockdown (e.g. a best estimate IFR above x%), and changes to those parameters should effect change in the policy.
The Imperial College London study that initially catalyzed the UK and US into lockdown referenced a 0.4–1.4% IFR with 95% confidence, but today, the CDC forecasts an IFR below 0.3% (R). Meanwhile, Covid-induced unemployment is rampant (DOL) and dramatically more severe for workers without a college degree and for workers of color, particularly Hispanic workers (Freakonomics); 90% of people who were furloughed or lost a job expect to return to their job (FRB), but economists forecast that to be closer to 58% (UChicago). The immediate threat of Covid focuses media attention on ‘deaths per capita’ figures, but those results should be considered alongside headlines like, “Child hunger soars to levels without modern precedent” (NYT). Prosperity is measured holistically.
“The problem with this approach to Covid-19 is that it assumes that the coronavirus is the only threat to health and well-being. Every day the fallacy of this assumption becomes more apparent… Our approach to pandemic containment works, but our approach to pandemic is causing suffering, eroding physical and mental health, and increasing the deaths of old people… [It] is typical of medicine and public health…articles in medical journals would detail the benefits of treatments, but few considered their harms.” (NYT)
But at this point, the issue of the lockdowns is less about whether or not it originally was the most prudent response but rather about what to do today. The narrative is shifting — individuals, politicians, and the media are discussing reopen plans as a balance between tradeoffs (e.g. 538, WSJ, NYT). If this were Ebola (which kills 25–90% of those infected, WHO), we probably wouldn’t be talking about reopening hotspots, and if this were seasonal influenza, we probably wouldn’t have ever gone into lockdown — but somewhere in between lies our happy medium. Emerging studies are unraveling the effects of various policies, but often conclude that, “it’s hard to discern how much of [the stay-at-home orders hospitalization impact] is associated with other factors like school closures, social distancing guidelines, and general pandemic awareness” (JAMA). And the question might be moot anyway, as “data suggest that lockdowns are much less consequential for either health or the economy than people might suppose…it’s less the lockdown policies than the judgment about what’s safe or not safe” (TAI).
It seems like we will end up with policies that embody Sweden’s approach, i.e. somewhere between lockdown and no precautions (a sentiment echoed by WHO). But while we went to the extreme public policy response of statewide lockdowns with gradual reopenings, Sweden mobilized a more moderate response that had the same end goal of striking that balance. And while Germany pursued the lockdown but has a strong history of preserving businesses and jobs during a recession (Bloomberg), the US went into patchwork lockdowns without the precedent or plan in place to effectively mitigate the economic pain. That’s my interpretation of what Obama was referring to when he said that, “More than anything, this pandemic has fully, finally torn back the curtain on the idea that so many folks in charge know what they’re doing” (NYT).
On the question of “freedom”
This became a hot topic because, for some Americans, the lockdowns represent an infringement of civil liberties (NYT). It’s worth addressing because ‘freedom’ is one of America’s most integral values. George Lakoff (retired Distinguished Professor of Cognitive Science and Linguistics at UC Berkeley) calls freedom “America’s most important idea…at the center of all other important ideas” (link); it is ranked as Americans’ most important political value (PSQ).
Acknowledging that freedom is so cherished, it’s important to have empathy with those who feel it’s at risk. I personally build that empathy (and think it’s kind of fun to do anyway) by resurrecting hardcore nationalist quotes like: “give me liberty or give me death!” (Patrick Henry) and “those who would give up essential Liberty, to purchase a little temporary Safety, deserve neither Liberty nor Safety” (Ben Franklin).
Personally, I don’t disagree that our liberty is in jeopardy; my identity is tied to being outside in nature, and the county where I quarantined closed all parks and open spaces in one of the country’s most strict lockdowns (PD). I think everyone lost something meaningful during shelter-in-place, whether it was saying goodbye to someone who passed away or celebrating an occasion or keeping a small business afloat, and for some people, not having the freedom to choose between those opportunities and the virus threat was soul-crushing. On the other hand, I also recognize that we have a precedent for mandating public health measures like seatbelts and helmets. Overall, I personally feel as though non-elected local health officials need checks and balances in place.
Conclusion
I’ll reiterate from part 1 that I don’t believe there is a necessary ‘right’ or ‘wrong’ Covid response. We are/were dealing with a new virus that caused confusion and fear. It presented a conundrum to government leaders who were damned if they do, damned if they don’t. Some information was emerging but most of it was incomplete and many voices provided perspectives that had conflicting resolutions. What I do expect from leaders is a very capable hand in making decisions and providing guidance through crisis. For leaders who chose the lockdown route, that’s their prerogative but I personally want to see more accountability for addressing the tradeoffs. I wish more diverse voices were questioning and discussing the validity of the original policy decision, as it has enormous consequences particularly for those who can defend themselves the least.
Something I’ve personally been reminded of throughout the Covid experience is another lesson in empathy and respect; just because someone disagrees with you or interprets information differently, the most productive and healthy way to navigate it is to validate them and listen. Thank you for reading this and listening to my perspective.
Something that Killer Mike recently said in light of the #BLM movement really resonated with me: “CNN…I’d like to say to CNN right now: karma’s a mother. Stop feeding fear and anger every day. Stop making people feel so fearful. Give them hope.” — this is taking his comments out of context, but I personally feel as though that type of panic-inducing journalism applied to Covid mid-crisis as well. To practice what I preach, let me try to share what I harbor as hope: while we face one of the most jarring economic retractions in history, many people who’ve dealt with stepbacks view them as “an opportunity to move yourself in a different direction” (Oprah on SGN), and that “for all the failings in America, there is absolutely a willingness to change” (Rework). So, what should we collectively do next? “It’s time to build” (Marc Andreessen); “let’s get to work” (Barack Obama).
