Month: March 2020

Beating covid-19: Compulsion or Persuasion and Guidance

March 31, 2020

The number of deaths in the U.S. from covid-19 have doubled every three days over the last 22 days amounting to 3,141 by the end of March 30. At that point there were 163,788 confirmed cases (those testing positive for the virus).  https://www.ft.com/coronavirus-latest  The actual number of cases is thought to be considerably larger but remains undetected because of limited viral testing.  America’s overall strategy for containing the virus is to isolate those infected in order to stop or slow its spread until a vaccine can be developed, tested for safety and effectiveness, manufactured and administered (one to two years after the discovery of the vaccine, with luck) or until enough of the population has acquired immunity as the result of surviving from the disease (herd immunization), i.e., almost everyone who gets it. The details of the approach vary from community to community.

The virus that causes covid-19 is spread from person to person. It can be picked up from surfaces touched by a sick person, coughed or sneezed into the air within six or so feet or by direct contact, but it can only enter one’s body via the month, nose or eyes.  “Prevent-getting-sick/how-covid-spreads”  “Protecting-yourself-from-coronavirus”  Thus those who test positive for the virus should be isolated from the rest of us (quarantined) and the rest of us should self-isolate if we experience symptoms of the disease. To protect ourselves from picking up the virus and bringing it to our faces we can reduce our social interactions (work from home, avoid public gatherings such as religious services, and restaurants, bars and public entertainment). Two measures are more important than any others: test as many people as possible in order to detect and isolate those with the virus and wash our hands with soap frequently.  The President’s coronavirus-guidelines for American

These measures can be imposed by government decree and enforcement by the state or can be urged by public education and voluntary individual actions. On March 17 the Governor of Virginia explained why he had not ordered restaurants and bars to close. “Northam said too many Virginia residents rely on restaurants for their meals to justify ordering they shut down.”  “Northam-adopts-10-person-standard-opposes-closing-restaurants”  For the United States as a whole and for most communities (public health services are administered by cities and states) the restrictions on our activities are voluntary. The specific guidance or rules are determined locally, thus providing useful data on which approaches work best.

As in Singapore, S. Korea, Japan, Hong Kong, Sweden and a few other countries, business closures in the U.S. have generally been voluntary until March 30. But unlike these countries, which have successfully kept death rates relatively low, the U.S. failed to undertake significant testing for the virus for more than two months after the outbreak of the disease in Wuhan, China. After the tenth death, the death rate from covid-19 in the U.S. has doubled every three days and passed the number of 9/11 deaths on March 30. On March 30, the Governor of Maryland, followed by the Governor of Virginia and the Mayor of the District of Columbia, made shelter in place mandatory: “We Are No Longer Asking Or Suggesting That Marylanders Stay Home, We Are Directing Them To Do So.” “As-covid-19-crisis-escalates-in-capital-region-governor-hogan-issues-stay-at-home-order-effective-tonight”

There is general agreement that testing should be pursued vigorously and those testing positive should be quarantined and their contacts tested, etc. This buys time to better prepare for the increased demand for medical care that will be needed and to develop treatments and vaccines. Though many will die needlessly in the U.S. because of a several months late start with such a program, the question remains which policy to follow for everyone else going forward.  Should it be government mandates to shut most things down and keep everyone home (or at least try to), or should we rely on the choices of each individual for how best to protect themselves and their loved ones while carrying on with their lives? What are the matrixes by which that choice should be judged? “This-pro-trump-coastal-community-in-florida-hit-early-by-virus-sits-at-emotional-nexus-of-national-debate-over-reopening-economy-amid-health-crisis”

In my opinion maximizing individual choices about how to respond to the epidemic is both more effective and more in keeping with America’s freedom loving culture. By more effective I mean that it will best slow the spread of the disease with minimal damage to the economy and the quality of our lives. We each have a strong incentive to protect ourselves from contracting the virus. We also care about protecting others from exposure (most strongly our families and loved ones) but can be deterred from that goal by the loss of income if we stay home. The CARES Acted signed into law a few days ago is meant to compensate firms that shut down temporarily and workers who stay home temporarily and thus to better align the incentives to protect others with the financial consequences.

We protect ourselves and others by diligently adhering to enhanced hygiene practices (frequent hand washing) and by reducing unnecessary social contacts (no hand shaking etc.). As with most everything else in life we are each better able to determine how best to balance the risks of social interactions (whether to work from home or in the office) with safer isolation, than are government officials making general rules for everyone.  The countries that have adopted this approach have left their citizens free to go to work or restaurants but undertaken extensive educational programs on the best practices to protect against transmission of the virus. “South-korea-keeps-covid-19-at-bay-without-a-total-lockdown”

South Korea, Singapore, Taiwan and other countries taking this approach provide their citizens with honest information needed by them to evaluate the risks of different choices. This includes information on who is infected and identifying infection hot spots. In the U.S. a person’s health status is private. But when a person carries a contagious disease into the public, his/her condition should be made known to those who risk exposure.  “Coronavirus-data-privacy”

Government mandates to shelter in place or cease many business activity will become increasingly difficult to enforce (have you watched the “Steven Soderbergh movie Contagion”). Persuading the public to adjust their behavior in ways that slow the virus’s spread and providing helpful guidance on how best to do so until a vaccine is found or most of the population becomes immune would be both more effective and more politically popular.

Covid-19: What should Uncle Sam do?

On February 29 the first person in the United States died from Covid-19, the disease caused by SARS-CoV-2, the so-called novel coronavirus first observed in Wuhan, China.  On March 12, three more people succumbed from this disease bringing the total to 41. Ten days later on March 22, 117 died bringing the total to 419 as the exponential growth of Covid-19 deaths continues. Globally 15,420 had died by midday March 23 and deaths are rising fast.

How and where will this end?  Shutting the economy down and keeping everyone isolated in place until the virus “dies” for lack of new victims would ultimately kill everyone from starvation (if not boredom).  This pandemic will only end (stabilize with the status of the flu, which currently kills about 34,000 per year in the U.S.) when an effective vaccine is developed and administered to almost everyone. This will take one year to eighteen months if it is discovered today, and that is if we are lucky that the safety and effectiveness trials go according to plan. Without a vaccine, the pandemic will “end” when most of us have acquired immunity to it as a result of having and surviving (as almost everyone will) covid-19 –acquiring so called herd immunity.  This assumes that having and surviving the disease will immunize us. This is generally the case with viruses but has not yet been established for SARS-CoV-2.

Our hospitals and medical services could not handle the patient load if every one contracted this disease over too short a period, so it is important to slow down the pace of infection–so called flattening the curve (which could spike quickly as you see from the opening paragraph). The ideal strategy is to allow the infection of those with low risk of serious illness or death to speed up herd immunity with minimum demand on our limited health facilities, while protecting and treating the most vulnerable. The young and healthy are least vulnerable and the old and health-impaired are the most vulnerable.  We should reopen schools and restaurants after Easter and gradually restart our cultural entertainment lives adhering to higher standards of hygiene and public interaction. This would be ideal both with regard to speeding up herd immunity and with regard to minimizing that damage to the economy.

What should government do?

I am from the government and I am here to help (it is risky to attempt humor in these times, but what the hell). “Treasury Secretary Steven Mnuchin warned GOP senators that the unemployment rate could spike to nearly 20 percent if they fail to act dramatically…. The United States is expected to lose 4.6 million travel-related jobs this year as the coronavirus outbreak levies an $809 billion blow to the economy, according to a projection released yesterday by the U.S. Travel Association…. Research from Imperial College London, endorsed by the U.K. government, suggests that 2.2 million would die in the United States and 510,000 would die in Britain if nothing is done by governments and individuals to stop the pandemic.” “six-chilling-estimates-underscore-danger-of-coronavirus-to-public-health-and-the-economy”

“Infectious disease experts do not yet know exactly how contagious or deadly the novel coronavirus is. But compared to SARS and MERS, SARS-CoV-2 [as the novel coronavirus is now labeled] has spread strikingly fast: While the MERS outbreak took about two and a half years to infect 1,000 people, and SARS took roughly four months, the novel coronavirus reached that figure in just 48 days.”  “Mapping the Novel Coronavirus Outbreak”

The U.S. does not have the medical equipment or hospital beds that will be needed for those anticipated to need ICU facilities.  And as poorly equipped medical staff fall ill from their exposure to the Coronavirus, we will run out of enough doctors and nurses to care for them forcing us to default to the unpleasant realities of medical triage where doctors begin to assess and choose those that have a higher probability of survival and to leave the weakest to fend for themselves. This has already started in Italy.

So, what should the government do? Its response might be considered under three categories:  a) Stop or slow the spread of covid-19; b) Help state and local health service providers care for those needing it; and c) minimize the damage to the economy (i.e. to those whose income is affected by the disease or the measures taken to slow the spread of the disease).

As with all good policies, as the government determines its immediate approaches to the crisis, it should keep one eye on the longer run implications of the policies adopted. It should balance the most effective immediate actions with the minimization of what economists call moral hazard in the future.  The simplest and best-known example of moral hazard results from the now hopefully banished practice of governments bailing out banks when they fail as a way of protecting depositors. This one way bet for the banks–they profit when they win their bets and the government bails them out when they lose them–encouraged banks to take on excessive risks. In the U.S. we have replace bank bail outs with deposit insurance and efficient bank resolution (bankruptcy) procedures. “Key Issues in Failed Bank Resolution”

If economists do nothing else, we pay very close attention to incentives, particularly those created by government rules and regulations (including taxes and subsidies).  Government financial assistance must also be carefully designed to be temporary, recognizing the danger that expansions of government into the economy in emergencies have the bad habit of becoming permanent.

From these general considerations our response should be guided by these principles: Measures should be effective with the least cost. They should be narrowly targeted. They should be temporary. The cost of financial assistance should be shared by all involved–no bailouts.

Flatten the curve 

The government’s first priorities must be to slow the spread of covid-19 while supporting the medical needs of those contracting it.  Limiting the number of infected will limit the resulting deaths (guesstimated to be around 1% of those infected by this virus). Slowing the rate at which people are infected–flattening the curve–will reduce the peak demand for hospital beds and related services until a vaccine is found (once one or several candidates are discovered today, it will take 12 to 18 months of tests to establish its safety and effectiveness and manufacture enough to start administering it).

Despite clear warnings that the novel coronavirus posed serious threats to the U.S. for which we were not prepared, President Trump failed to act until very recently, calling the scare a Democratic plot as recently as February 28. “Trump-says-the-coronavirus-is-the-democrats-new-hoax”  “U.S. intelligence agencies were issuing ominous, classified warnings in January and February about the global danger posed by the coronavirus while President Trump and lawmakers played down the threat and failed to take action that might have slowed the spread of the pathogen, according to U.S. officials familiar with spy agency reporting.” “US-intelligence-reports-from-january-and-february-warned-about-a-likely-pandemic”

Countries that acted quickly to identify and isolate those infected by the virus have generally succeeding in slowing its spread without shutting their economies down.  South Korea, Singapore, and Taiwan have tested widely and quarantined those testing positive, many of whom were asymptomatic. Their economies have not been shut down. Restaurants and bars remain open as do schools in Singapore and Taiwan.  New cases in S Korea have fallen to very low levels two weeks ago and active cases have been declining since March 11 as more people recover than acquire the disease. On March 22 only two people died from the disease.  Cases and deaths have remained low in Japan, Singapore and Taiwan. The following describes the lesson’s from Singapore’s success: plan ahead, respond quickly, test a lot, quarantine the sick, communicate honestly with the public, live normally:  “Why-Singapore’s-coronavirus-response-worked–and-what-we-can-all-learn”

As a result of the U.S. failing to act earlier, the potential for this approach has been reduced in the U.S.  Nonetheless, the government should urgently remove its barriers to testing, increase the supply of tests, and pay most of the cost of testing. In order to discourage frivolous testing those being tested should pay a small amount of the cost (e.g. ten dollars per test).  Even today (March 21) very few Americans are tested despite frantic catch up efforts by the U.S. government.  “A-government-monopoly-led-to-botched-covid-19-test-kits-but-private-labs-are-now-saving-the-day” Positive test results (“cases”) in the U.S. are rising rapidly (983 new cases on March 16 jumped to 9,339 on March 22, for a total of 33,546). However, as so little testing has been possible, there is no way we can know whether this dramatic increase reflects increases in infection or only the increase in the identification of existing infections. “Peggy Noonan gets tested–finally”

As a result, the government has urged people to stay home, and most entertainment centers (theaters, cinemas, restaurants, gyms, and bars) have closed, and a few state governors are mandating it.  Many international flights have been cancelled.  Aside from grocery stores and pharmacies, most shops and malls have closed. A controversy is raging over whether closing schools does more harm than good. Among the arguments against it is that because serious illness and death among the young is rare but they can spread the disease (to their families at home and others), attempting to block their infection interferes with herd immunization (protection from infection as the result of a large proportion of the population becoming immune as the result of recovery from infection).

The economic impact of those drastic measures will be explored below, but the government must now urgently prepare for the surge of covid-19 patients promising to overwhelm our brave medical health care workers, medical supplies and hospital beds even with these draconian measures. Priorities must be given to properly equipping medical service providers and training their replacements as they fall ill. Hospital beds and respirators and other equipment needed for the more seriously ill must be urgently produced, in part by turning out and away, less seriously ill patients and those with non-emergency, elective treatments. We can delay the investigation into why these steps where not taken two months ago when the need was identified.

Care for the sick

The government should support the market’s natural incentives to develop better treatments and ultimately a vaccine (i.e. profit). This raises challenging policy issues. Protecting the patent rights of firms developing treatments protects the profit incentive for them to do so. However, the sharing of research findings, thus threatening such patents, can greatly accelerate the discovery of helpful medicines or procedures. Hopefully rights can be established and protected that both encourage drug development and cooperative information sharing.

The failure of the U.S. government to provide for or allow significant testing for covid-19 is a scandal. The government should get out of the way. “Coronavirus-and-big-government” Its claim last week and the week before that testing was opening up is sadly not true.  By March 19th the U.S. with a population of 327 million had only tested 103,945 people (0.03%).  S. Korea with a population of 51.5 mil. had tested 316,664 by March 20th (0.6%) and Germany with a population of 82.9 mil. had tested 167,000 by March 15th (0.2%)  “Covid-19-why-arent-we-prepared”

President Trump’s trade war has damaged world’s ability to fight covid-19 in general but more specifically his tariffs on medical supplies are contributing to their shortage in the U.S.  “The US-China trade war has forced US buyers to reduce purchases of medical supplies from China and seek alternative sources. US imports of Chinese medical products covered by the Trump administration’s 25 percent tariffs dropped by 16 percent in 2019 compared with two years earlier.”  “Tariffs-disrupted-medical-supplies-critical-us-coronavirus-fight”

Save the economy

Having missed the opportunity to flatten the curve via testing and targeted quarantines, the U.S. has taken much more drastic steps to restrict public interactions, shutting down the entertainment, educational, and transportation sectors of the economy. These should result in temporary interruptions of the supply of these services that will bounce back when the restrictions are lifted. Some output will be lost forever (lost classroom time, and restaurant meals) but others can be recouped or at least restored to original levels (rates). Clothing and other retail items not purchased during the shut down can be purchased later.

What the economy will look like afterward (hopefully only a few months) will depend on several factors. The first is the extent to which our public behavior is altered permanently. Home movies might permanently replace some part of our usual attendance to the cinema. Teleconferencing might permanently reduce meeting travel or accelerate the existing trend in that direction, etc.

The policies being debated in congress at this moment for protecting individuals and firms from the financial cost of the temporary shutdown can profoundly affect the future composition and condition of the economy. Every big firm out there is working on how they can tap some of the taxpayer’s money that government will be giving out. Those pushing government interventions into new areas on a permanent basis will exploit the occasion to slip in their favorite policies. Unfortunately, once the government moves into an area– it rarely withdraws. Almost 19 years later, the horrible Patriot Act, adopted when a scared public was willing to trade off liberty for security, is still largely with us.

Our public interest would be served by incentives that lead those who might be sick with covid-19 to stay home rather than risk infecting others, and by policies that enable viable firms that lost customers and individuals who stayed home to bridge their financial gap until returning to normal. Affected firms and individuals will continue to have expenses (food, rent, mortgages, etc.) but no incomes. They should be provided with the funds to meet these expenses in order to return to life/work when the lights go back on. The sharing of the cost of those funds must be considered politically fair and must incentivize the desired behavior. Everyone must have some skin in the game (a share of the cost). Adopting measure that fill those criteria will not be easy.

The government (taxpayers) should cover much of the cost of the covid-19 related medical services and hospital costs, including very widespread testing. Medical service providers should be tested daily (e.g., several doctors have died from covid-19 in Italy). Anyone staying at home and testing positive should receive sick leave paid for by the government.

Assistance to companies and the self-employed should be as targeted as possible on those forced to reduce or stop operations as a result of covid-19. Where possible, assistance should take the form of loans to companies that continue to pay wages to their employees even if not working. Restrictions should be placed on how such loans are used (no stock buy backs, or salary increases during the life of the loans). Bank and lending regulators should allow and in fact encourage temporary loan forbearance by the lenders on temporary arrears from otherwise viable firms. “Bailout-stimulus-rescue-check” One small businessman convincingly argued that wage subsidies that keep working on the payroll are better than generous unemployment insurance, which makes it easier for firms to lay off their workers. “Dear-congress-i’m-a-small-business-owner-heres-what-my-business-needs-to-survive”

What about the big companies, such as Boeing, the airlines, the Hotel Chains, and Cruise ship operators? Yes, they should be included in the loan forbearance and incentive loan programs, but they should receive no special consideration beyond that. If government (partially) guaranteed loans through banks to pay wages and other fixed expenses for a few months are not enough to finance a firm’s expenses without income for a few months it is probably not viable in the long run anyway and should be resolved through bankruptcy as were GM and Chrysler in earlier financial crises. This would wipe out the stakes of owners while preserving the ability of the firm to return to profitable operation with new owners. “Bailing-out-well-if-bail-out-we-must”

Monetary policy

The American economy (and elsewhere) is suffering in the first instance a supply shock (sick people unable to work and produce). This fall in income from supply disruptions also reduces demand. Cutting the Fed’s already low interest rate target to almost zero is a mistake. No one will undertake new or expanded investments because of it, and its impact on reducing the return on pensions and other savings will, if anything, reduce spending. The last decade of very low interest rate policy targets has already contributed to excessive corporate debt and inflated stock prices (recently deflated back to normal).

Injecting liquidity via new lending facilities and international swap lines, as the Fed is now undertaking, is the correct response. If lenders allow their borrowers to delay repayments for a few months, they need to replace that missing income somehow (rather than calling in nonperforming loans and bankrupting the borrower). The Federal reserve should substitute for that income by lending to banks freely against the good collateral of government debt or government guaranteed debt.

“The vital need of everyone in the economy, from the corner drugstore to the local transit authority to the mightiest multinational, is liquidity: credit to meet payroll and other key obligations so as to remain solvent until the end of what we all must hope is a finite crisis.”  “Here’s-an-economic-aid-plan-better-than-mitch-McConnell’s”

Macroeconomic policy

As noted above, the government’s help should be narrowly targeted to the direct victims of covid-19.  A general fiscal or monetary stimulus is not needed or desirable.  Nonetheless, it will add to the federal debt that is already bloated by years of annual deficits at the peak of a business cycle when a surprise is customary and appropriate.

“The United States is not confronted with a financial crisis and a follow-on crisis of demand, as in 2008 or 1929. Rather, previously robust consumption and production are being deliberately halted to save lives. Thus, traditional tools of monetary and fiscal stimulus, such as zero interest rates and direct cash aid to households, are unlikely to prove decisive. You can’t shop, or invest in new construction, while on lockdown.”  “Here’s-an-economic-aid-plan-better-than-mitch-McConnell’s”

This is a dangerous period both for our personal health and for the health of the economy. Affected firms should be helped in order for them to continue paying their employees and to remain solvent until they can return to production. But the United States has failed to prepare properly and is handling the fight against covid-19 poorly. We need to reopen our schools and restaurants and return to normal at a reasonable pace while allowing herd immunity to develop at a faster pace while supporting the most rapid development of a vaccine possible. Don’t fight this wildfire with our eyes shut while enhancing the dangers of future fires from ill-advised measures undertaken in this emergency environment.

Stay strong everyone. We will all get through this.

Social Distancing

Research lead by Neil Ferguson and his colleagues at Imperial College London suggests that a staggering 2.2 million would die in the United States and 510,000 in Britain if nothing is done by governments and individuals to stop the pandemic (no social distancing or hand washing, etc.).  Imperial College London study  The U.S. was late and bumbling in addressing the Novel Coronavirus coming from China in December. The Food and Drug Administration (FDA) refused to authorize the use of tests approved by the EU and the test developed by Centers for Disease Control and Prevention (CDC) was flawed and had to be withdrawn. The United States remains embarrassing and dangerously behind other countries in testing and other preparations for dealing with the disease.  “Coronavirus-testing-delays-caused-red-tape-bureaucracy-scorn-private-companies”

Unable now to contain the virus in a targeted way, the U.S. has largely shut down its schools, theaters, restaurants and other places of public gatherings as well as flights from abroad. The Ferguson “report concludes that the British government might be able to keep the number of dead below 20,000 by enforcing social distancing for the entire population, isolating all cases, demanding quarantines of entire households where anyone is sick and closing all schools and universities — for 12 to 18 months, until a vaccine is available”. A comparable figure for the U.S. implies a reduction in the death rate to 86,000.

For perspective, traffic accidents in the U.S. in 2017 killed 40,100.  More than forty-seven thousand committed suicide that year and 55,672 died from influenza and pneumonia. When compared with ordinary flu, covid-19 spreads more rapidly and is ten times as deadly, but we still do not know very much else about its properties.  But, we can expect a relatively large number of deaths from this new virus no matter what we do.  But doing nothing will increase deaths considerably.

What steps should the U.S. take?  We don’t ban cars because people die in them. We choose to take calculated risks if they are not “excessive”.  https://wcoats.blog/2016/12/27/our-risks-from-terrorists/

The extreme measures being taken in the U.S. proceeded without serious estimates of the economic costs to the economy and the spill over health risks of children kept home with vulnerable grandparents, etc.  “The CDC guidelines advised that short- and medium-term school closures do not affect the spread of the virus and that evidence from other countries shows places that closed schools, such as Hong Kong, ‘have not had more success in reducing spread than those that did not,’ such as Singapore.  But this guidance was not released until Friday [March 13], after the cascade of school closings had begun.”  “States-are-rushing-to-close-schools-but-what-does-the-science-on-closures-say”

Our extreme reaction will generate huge costs that cannot be fully known reverberating for years to come. We can be pretty certain that there will be unintended, undesirable consequences quite beyond the disruption of our pleasurable, cultural activities (bankruptcies of otherwise viable firms and the resulting loss of jobs, etc.). The government (congress and the administration working together for a change) is attempting to anticipate and ameliorate as many of those consequences as possible. One example of the search for cost effective balance of cost and mitigation involves the stopping of flights from Europe.  The cost of monitoring arriving airline passengers before boarding abroad is very likely cheaper than the economic disruption and damage of forbidding foreign visitors at all.  Following Trump’s announcement of the travel ban (once his team sorted out and clarified what he was actually imposing) the American Civil Liberties Union announced, “These measures are extraordinary incursions on liberty and fly in the face of considerable evidence that travel bans and quarantines can do more harm than good.”

Unlike the U.S., Britain has not closed its schools and restaurants. But as I am writing this, the UK just announced that its schools will close Friday March 20.  The Patriot Act passed quickly after the 9/11 terrorist attacks in the U.S. on September 11, 2001 (for those of you too young to remember) reminds us how quickly and easily we surrender our revered liberties when we are scared.  Almost 19 years after 9/11 we still have the dangerously intrusive provisions of the Patriot Act.  Once freedoms are surrendered and the government steps in it seems to be hard to regain them.  The extreme measures being taken in the U.S. and elsewhere to slow the spread of covid-19 provide us with the latest example.

On March 16, Deborah Birx, White House coronavirus response coordinator, reported that models based on data available so far indicated that the biggest reduction in deaths came from “social distancing, small groups, not going in public in large groups. But the most important thing was if one person in the household became infected, the whole household self-quarantined for 14 days. Because that stops 100 percent of the transmission outside of the household,”

The biggest bang for the buck comes from individuals protecting themselves by social distancing, hand washing, and normal (and perhaps enhanced) care to avoid the sick and avoid exposing others when we are sick as we generally do now. Clear public health guidance from the government could go (would have gone) a long way to encourage the enhancement of such diligence.  The Kennedy Center for the Performing Arts never closed down during the flu season.

Covid-19 calls for vigorous government action, even now when it is too late to stop it any time soon. We will need extra hospital beds, medicine, respirators, protective gear, replacements for infected health workers, vaccine research, development, manufacture and administration and more.  Soon we will require replacements for the many brave health care workers such as nurses and doctors as they also become infected with the virus. But as with all decisions, private and public, a careful assessment of costs and benefits of different courses of action will produce the best result.  Knowledgeable public information to guide the natural protective self-interests of each of us and our usual concern and respect for the well-being of our families, friends and neighbors can carry us a long way toward minimizing the further spread of this disease at minimal cost to lives and property.

P.S.  In my previous blog of March 15 (Covid-19, why aren’t we prepared) I reported Beth Cameron’s claim that the National Security Council Directorate for Global Health Security and Biodefense was disbanded in May 2018.  Ms. Cameron was its director at the time.  Yesterday Tim Morrison, director of the successor unit for a year in 2018-19, “No-white-house-didn’t-dissolve-its-pandemic-response-office”, explained that its staff and function were merged with two other units performing overlapping functions in order to improve efficiency without a loss of its capacity “to do everything possible within the vast powers and resources of the U.S. government to prepare for the next disease outbreak and prevent it from becoming an epidemic or pandemic.”  I apologize for misrepresenting what happened and expect Mr. Morrison to apologize for the disastrous failure of his unit to fulfill its mandate.

Covid-19, Why Aren’t We Prepared?

Following the Ebola epidemic of 2014 President Obama established the National Security Council Directorate for Global Health Security and Biodefense “to do everything possible within the vast powers and resources of the U.S. government to prepare for the next disease outbreak and prevent it from becoming an epidemic or pandemic.” “NSC-pandemic-office-trump-closed”.  This unit was “disbanded under a reorganization by national security adviser John Bolton” in May 2018.

America’s disorganized and late starting response to the spread of Covid-19 in our country can be attributed in part to this act. What was obviously a mistake with the benefit of hindsight, however, was a more difficult judgement at the time. Two classes of judgements were involved: a) what organizational structure would service the country’s interests best (for Bolton, everything always seemed focused on the preparation for war), and b) how many and what resources should be devoted to events that might never occur?

The government’s role in disaster management is spread between a number of agencies, from FEMA (Federal Emergency Management Agency), the Department of Homeland Security, the Department of Health and Human Services (HHS), Food and Drug Administration (FDA), and the Center for Disease Control and Prevention (CDC), to state and local health services, fire departments etc. I have no idea if each potential disaster is managed by the most appropriate agency but coordination between them is often very important. That requires designated leadership.

Assigning resources to prepare for dealing with possible future epidemics means not assigning them to something also of value. What are the tradeoffs? We keep emergency reserves of many things: oil, medicine, face masks, excess capacity at hospitals, etc. What is the right amount? We keep a large military in case of war that we hope will never occur (unfortunately we have very foolishly used them unnecessarily too often and in too many places). What is the right size of the military given that every additional soldier is one fewer of whatever else she might have done?  Keeping a military reserve that can be called up in the case of war is one of the approaches we have taken in dealing with this question.

It is hard to impossible to know for sure the best answer.  Devoting resources to being prepared for an event that never occurs might seem (increasingly) wasteful. But so might an insurance policy for something we hope never happens, and we are generally wise to have it. Not taking the time and resources to be prepared can be extremely costly if the disaster occurs.  Large banks are now required to test the resilience of their balance sheets against financial shocks of one sort or another (stress tests) and to prepare living wills for how they would be liquidated if they became insolvent. These are costly exercises but well worth the cost if it helps avoid bank failures and/or makes the orderly liquidation of an insolvent large bank feasible, thus making market discipline of excessive bank risk taking credible. https://wcoats.blog/2012/06/29/spains-financial-crisis-first-principles/

There are rumors that the HHS blocked the use of foreign tests for the Coronavirus to preserve business for American pharmaceutical companies and that President Trump exempted the UK and Ireland from his initial European travel ban because he owns golf courses in Scotland and Ireland may or may not be true. https://wcoats.blog/?s=crony+capitalism.  Fortunately, we still have a free press, which is likely to get to the bottom of that.

Where the stakes are high, we should pay the cost of reasonable preparations for disasters of one sort or another. The lives of tens of thousands of citizens are at stake. Getting the balance right, as in so many other areas of governance is not easy. But the United States today is neither well organized nor properly prepared to mitigate the damage of the epidemic now about to sweep over us.  We will pay a much larger cost for this than we should have.

However, it is not only the country’s lack of preparedness that is a major problem in this national crisis. The President himself appears unprepared to handle facts or rely on his medical experts and convey confidence to the public by making accurate statements about what is being done and what the public should expect. His recent oval office statements about an all-encompassing Europe travel ban including the banning of cargo coming from Europe and the availability of free tests and treatments was basically wrong. Each claim had to be corrected and re-explained in an already confusing and panic-induced environment. The White House has not presented a clear, coherent plan for containing the damage of covid-19 that the Trump’s own administration understands or is behind.  Along with starting late to address the challenge, the Trump administration has been and remains incoherently organized to move forward from here. Stay tuned for the next tweet.

Protecting yourself from Coronavirus

How can you best protect yourself from coronavirus? Unfortunately, the “government” is providing inconsistent and sometimes misleading advice, as are airlines and other businesses that want to keep you coming.  Disinfecting surfaces and extra cleaning of airplanes and other public transports may not be helpful and can communicate a false sense of safety. You would be safer to sit on an uncleaned toilet and then wash your hands, than to clean the toilet seat yourself with some disinfectant.

Two key facts are critical to understanding the transmission of viruses, such as Coronavirus. The first is that not all disinfectants are created equal.  Most are effective in killing bacteria but not viruses.  By and large only products with bleach (Clorox or sodium hypochlorite) will destroy viruses, but they can potentially also destroy the surfaces they are applied to, including your skin and thus it is not desirable to use them routinely. The second fact is that the coronavirus does not enter your body through your skin. It enters through your eyes, nose or mouth (or an open sore). This is why you should avoid touching your face.  Your best protection is to keep the virus off your hands, and then keep your hands off your face. The best way to keep the virus off your hands is to be more careful where you put them and to wash them with ordinary hand soap whenever you think your hands might have contacted the virus.

Wash your hands:  “If we sanitize, it will be fine.” No it won’t. Saying so can give a false sense of safety. Products to disinfect your hands without rinsing might kill bacteria but they will only rearrange viruses on your hands. Even ordinary soap will not “kill” viruses, but it is great at removing them from your skin so they can be rinsed away. Wash for 30 seconds (humming the “happy birthday to you” song twice) and rinse well. The following article provides an excellent and detailed discussion of the power of soap: “Deadly-viruses-are-no-match-for-plain-old-soap-heres-the-science-behind-it”

Don’t touch your face:  The most reliable measure of protection from acquiring covid-19 is to avoid touching your eyes, mouth or the inside of your nose. These are the access points for viruses into your body. This is easier said than done. See Ito’s suggestions below.

If you are young, don’t worry and have fun. That’s what the young do anyway. If you are my age, keep a distance from others and try not to touch anything (especially someone else’s hands). Stay home more. It will also allow time to develop better treatment protocols, increase isolation ward capacity, and a vaccine (which, however, will take another year or more to test for safety and effectiveness).

In the following, Dr. Victorino (Ito) Briones, MD, Ph.D., provides the most relevant tips on how to prevent getting infected with the Coronavirus

  1. The most significant source of infection will be your hands.

We always use our hands in order to go about our daily routine. We touch the doorknob to open the door, hold the grocery handle from a cart or a basket, shake hands, etc. Do not be afraid to get the virus on your hands. Our skin is one of the best defense barriers from this virus. It will not infect you even if you have touched an object or another person’s hand that has the coronavirus. The way the virus can get into your body is by entering through your mucous membranes, which in this case includes your eyes and your mouth as well as the inside of your nose.

Suggestions:

  • Do not touch your face. Again, don’t worry that you might have the virus in your hands. But don’t transfer the virus from your hands to your face where it can enter and infect you through your eyes, mouth and nose.
  • Wash your hands with soap and water. Do this most especially before eating.

NOTES: Most often public toilets will have a liquid soap dispenser. Be mindful that the top of the bottle may be contaminated with the virus by the previous person who used it. Be careful when you use bar soaps as the virus may survive in the soap bar as well. Also be mindful that the faucet knob or handle may be contaminated with the virus so do not close the faucet with the hand you just washed.

The CDC suggests about 30 seconds of washing. I personally like to wash once with soap first, then rinse and then wash again a second time. Please understand that soap and water do not kill the virus. Washing simply removes the virus from your hands.

  • Wrap a masking tape around the tips of both your forefingers.

It is extremely difficult to consciously prevent ourselves from touching our face.    Research says that we touch our face about 20 times an hour and we may not be aware we’re doing it. Wrap a masking tape (blue or orange) around the tips of your forefingers. The hope is that the masking tape at the tip of the forefinger will remind you not to scratch our face with your hands. Also, the sensation of the tape on the face should immediately tell you to stop.

  • What about Masks?

Masks are most helpful to those who already have cough and colds symptoms and this prevents them from spreading the virus in the air. Wearing masks, however, can be helpful in reminding you not to touch your face especially your mouth. But personally, I don’t find it essential.

  • Hand sanitizers?

A friend showed me a hand sanitizer he was using and the label said “antibacterial”. Antibacterial sanitizers do not kill viruses. Bacteria and viruses are very different organisms. CDC recommendations here: https://www.cdc.gov/handwashing/show-me-the-science-hand-sanitizer.html

Personally, I don’t like to recommend hand sanitizers because it may give the person a false belief that his hands are virus free. My recommendation is to think that your hands are always contaminated with the virus.

  • How to scratch your face/eyes?

It may be time to carry a pack of tissues with you. If you feel the urge to scratch your eyes, use a clean tissue from the pack. Make sure that your fingers don’t touch your eyes or face. Then discard the tissue into a trash can after using. Do not re-use the tissue. Be mindful that if your hand is contaminated, then the tissue is also now contaminated with the virus.

    2.  It might be time to change some personal habits.

  • No more shaking hands and embracing when greeting other people. At this time, people already understand and, I think, appreciate that this form of greeting is no longer appropriate.
  • Perhaps start the standard of using virtual fist bumps or elbow bumps to acknowledge personal greetings.

In general, always consider the possibility that everything you touch is potentially contaminated with the virus. But also understand that the virus cannot enter your body through the skin on your hand.  So don’t be afraid to go about your daily lives. However, be always mindful that the virus can enter your body through your face. Your hands are the most probable source of infection.

 

Coronavirus and You

If you are infected by the coronavirus, i.e. if you contract covid-19, what is the probability of your dying from it?  What is the death rate of this particular virus?  On Tuesday March 3 the World Health Organization (WHO) stated that the global fatality rate was 3.4 percent. The figure changes daily, but if we take this to be a correct measure (it isn’t as I explain below), your own probability of dying from the disease will be higher than that if you are older and/or suffer from other health immune compromising conditions and lower if you are young and healthy, etc.  Oh to be young and healthy again.

Yesterday, Friday March 6, the WHO reported 3,400 deaths worldwide and 100,000 confirmed cases worldwide. This is the basis of the 3.4% death rate. 3,400/100,000=0.034=3.4%. The true figure is probably lower, but it could also be higher. The numerator of this fraction–deaths–should be pretty certain. However, mistakes can be made in stating the cause of death.  A covid-19 death could be missed and attributed to something else.

The biggest probable source of error is with the denominator: the number of cases. There is a high likelihood that many who have contracted the disease have not yet and may never be diagnosed to have it.  It is likely that these missed cases are milder than those that are identified and thus have lower death rates. The U.S. has been particularly slow in testing for the coronavirus. The number of test kits needed to perform such tests are still very limited in the U.S.  As of yesterday (Friday March 6), the U.S. had only tested 1,890 people of which about 10% were positive. By comparison South Korea has been testing about 10,000 people per day for weeks. To the extent that the actual number infected with the virus is larger, and probably much larger, than those identified, the denominator will be larger and the death rate lower.  By comparison in the 2017-18 flu season in the U.S. 45,000,000 had the flu and 61,000 died.

But that is not the end of the challenges to an accurate figure for the death rate. The 17 deaths so far in the U.S. may, and probably does undercount the number who will die from those currently infected. If some of those already infected will subsequently die, the true death rate will be higher. The true figure will only be known sometime after the event. The following article provides a very good discussion of this issue. https://www.washingtonpost.com/health/coronavirus-mortality-rate/2020/03/06/b0c4cdfc-5efc-11ea-b014-4fafa866bb81_story.html

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Dr. Briones adds the following description of a more scientific approach to estimating the death rate.

There is the “TRUE” death rate and there is the “EXPECTED” death rate. The True death rate answers the question of how many people died from a particular disease event. The expected death rate represents the more computable number when people ask for the probability of dying from coronavirus infection.

TRUE death rates can only be computed after the “event” has finished and all people involved have been counted including those that survived the event and those that died from the event. For example, a pile up car accident involving, say 100 people, with 20 deaths would have a TRUE death rate of 20%. The TRUE death rate in this situation can be calculated accurately because the event has finished and is no longer evolving. No more people will be involved in this particular situation in the future.

In the present coronavirus epidemic, the TRUE death rate CANNOT be computed because the infection and disease continue to evolve and increase. It remains impossible to determine how many people actually have been infected with the Coronavirus as compared to those who have been tested and found to be positive for the virus. Also, most importantly, the TRUE death rate cannot be established because all those that have been tested positive have not finished the disease process. The TRUE death rate requires knowing the number of people that recovered/survived after coronavirus infection as opposed to those that died from the infection. Since the present situation of the Coronavirus epidemic continues to spread and infect more people, the result cannot be computed. This may be possible after the Coronavirus epidemic has been contained and new infections have been significantly minimized.

The better computation to answer the question of probable mortality rate from Coronavirus infection would be the EXPECTED death rate. In this computation, a randomly selected group of individuals from the pool of people who have tested positive from the Coronavirus are followed to the end of the disease process. (This approach assumes that this group is representative of the whole population infected by the Coronavirus.) So far, people infected with coronavirus either recover after two weeks or so or they die from the disease due to respiratory distress.

For example, 100 people are randomly selected from those positive for the Coronavirus. After a month or so, these 100 people would either have recovered or died from the infection. If 2 people died from this selected group, then the expected or probable death rate would be 2%. One important key point in this experiment is to follow the disease process to its conclusion of either recovery or death.

To increase the “Power” of the result of this experiment, researchers can further increase the randomly selected population from 100 to 1000 or even 100,000. But it is important that those selected to be part of the final computation (number of deaths divided by the total population) should have finished the disease process.

To increase the accuracy and power of the EXPECTED/PROBABLE death rate is to further categorize the selection by age group. For example: 20 to 40 years of age versus 50 to 70 years. Another refinement of the group selected can address older people with underlying conditions selected for the study. Further refinements of this population group can be made in order to accurately answer the question of: What is my (male vs. female, young versus old, no underlying disease versus one with underlying disease, etc) probability of dying from Coronavirus infection.

With already over 100,000 Coronavirus infections around the world, these numbers and computations can be done on a retrospective analysis of the various population groups.

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WC: The above approach should produce a more accurate estimate of the death rate if the death rate of those testing positive is representative of the death rate of those not tested.  It is reasonable to assume that those who were not tested but had the infection and where thus not part of the population from which the test sample was drawn, had a milder reaction to the infection and thus probably a lower death rate (possibly even zero).  Thus the “expected” death rate computed in the way explained by Ito above would be a maximum expected rate and the actual rate is likely to be lower.