Grasping Reality on TypePad, by Brad DeLong

When the Chinese government shut down Wuhan on January 23, quarantined another 15 cities the next day, and then extended a nationwide social-distancing mandate until the end of the Lunar New Year, it was clear that the world was in trouble. By as early as January 31, Western health officials–including Anthony Fauci, the director of the US National Institute of Allergy and Infectious Diseases–had acknowledged that the coronavirus could be transmitted by people without symptoms.

As officials at the US Centers for Disease Control and other public-health bodies surely must have recognized, asymptomatic transmission means that the standard method of quarantining symptomatic travelers when they cross national (or provincial) borders is insufficient. It also means that we have known for almost two months that we were playing a long game against the virus. With its spread more or less inevitable, the primary task was always to reduce the pace of community transmission as much as possible, so that health-care systems would not be overwhelmed before a vaccine could be developed, tested, and deployed.

In the long game against a contagious virus, how to mitigate transmission is no secret. In Singapore, which has largely contained the outbreak within its borders, all travelers from abroad have been required to self-quarantine for 14 days, regardless of whether they have symptoms. In Japan, South Korea, and other countries, testing for COVID-19 has been conducted on a massive scale.

These are the measures that responsible governments take:

• You test as many people as you can.
• When you locate areas of community transmission, you lock them down.
• At the same time, you build a database of all those who have already developed immunity—and thus may safely resume their normal routine.

In the two months since the threat of a pandemic became obvious, the United States has tested an estimated 484,062 people–South Korea has tested tens of thousands in a single day. There has been no nationwide random-sample time series constructed for the US. Many people who have shown up in health-care settings with symptoms have not been tested, and have instead been sent back into the community. Judging by the rate of growth in the number of reported cases, the US has performed worse than any other country, including Italy, Spain, and possibly even Iran.

Worse, the 69,197 cases reported in the US (as of March 26) are just the tip of the iceberg. From the 1,046 US deaths so far recorded, we can infer that 15,000-50,000 cases were active at the start of March, and that this figure will reach anywhere from 120,000 to one million in the next week. But that is just a guess; in the absence of testing, we really have no idea where we stand.

As such, the US has few options. The longer the government delays imposing a Wuhan-style lockdown, the less effective future social-distancing measures will be in the weeks and months ahead. Trump and Secretary of the Treasury Steven Mnuchin appear to want to roll the dice, placing an existential bet on America’s future by hoping that the pandemic will peter out with warmer weather. A more likely outcome is that many states’ health systems will collapse before that happens, leading to a spike in the COVID-19 mortality rate as the number of symptomatic cases soars–perhaps to as many as 50 million–in the coming months.

This potential disaster is entirely unnecessary. A lockdown could be rolled back within just three or four weeks if it is properly implemented. During that time, the public-health system could do its job: testing a random sample of the population, tracking the contacts of those with symptoms, and resupplying an already sapped health-care system while scaling up efforts to develop a vaccine and more effective treatments.

After a month or so of this, the businesses that were functioning as of March 1 could probably restart. The policy response could ensure that nobody loses their livelihood as a result of anything that happened between March 1 and May 1. In the meantime, the production and distribution of medical tests, food, utilities, and activities that do not involve human contact would represent the full extent of the economy. Absolutely everything else would be temporarily shut down.

After a month would come a Jubilee: the government would assume all debts incurred during the shutdown, sparing businesses from bankruptcy. The significant increase in government debt would then justify a highly progressive tax on income and wealth, both to reassure investors that long-term public finances are sound, and to recoup some of the unearned gains of those who have managed to profit from the lockdown.

Unfortunately, what the US should do is not what it will do.

The country is desperately short of tests and other critical supplies, and the Trump administration has shown no inclination to do anything about it. Here in Berkeley, hospitals are running short of surgical masks and asking for donations. Their plight is symptomatic of an underlying condition that has inevitably aggravated the current public-health crisis.…

#cvoronavirus #highlighted #orangehairedbaboons #projectsyndicate #publichealth #2020-05-29

THE ORIGINAL DRAFT FROM MARCH 23, 2020:

I confess that I had never thought that even the Trump administration would be so incompetent as to make testing the first key bottleneck.

When the Chinese government shut down Wuhan City on January 23, shut down another 15 cities on January 24, and then on January 27 enforced social distancing via extending the nationwide mandatory extended Lunar New Year Season holiday, it was clear that the world was in trouble https://www.china-briefing.com/news/china-extends-lunar-new-year-holiday-february-2-shanghai-february-9-contain-coronavirus-outbreak/. In late January Chinese province after province extended he mandatory closing of non-essential enterprises. And on January 31 western health officials including Anthony Fauci acknowledged that Chinese Minister of Health Ma Xiaowei had been correct when he had warned that asymptomatic transmission of coronavirus was a thing https://www.nejm.org/doi/full/10.1056/NEJMc2001468?query=featured_home.

At that point it became clear to me and, probably, much more clear to CDC and NIH that standard public health quarantining of symptomatic patients when they cross national (or provincial) lines would not be enough to control the spread of COVID-19. And it became clear that humanity was playing the long game against the virus: that it would spread and become endemic in humanity, and that the task was to slow down its spread so that health-care systems were not overwhelmed with patients and collapsed, and so that our virologists could produce treatments and vaccines before the bulk of the caseload occurred.

At that point—the end of January—it became clear to me and, probably, much more clear to CDC and NIH that the first requirement to developing a strategy was: test, test, test. Test patients presenting with symptoms. Trace and test their contacts. Do what Japan and Singapore did—close to the epicenter in Wuhan, yet still with true caseloads lower than one in ten thousand. Test those crossing borders, symptomatic or not. Test a random sample of the population to see whether and how much the disease was established, and then test another one. here community transmission has become established, apply the Wuhan lockdown for at least three weeks, so the caseload could be diminished enough so that contact tracing could be resumed. Build up a database of those who tested positive and were presumably now immune so that they could be on the frontlines of treatment and contact with those possibly newly infected.

Ramp up the testing program as fast as possible so that we could at least know where we were, and have at least a chance of figuring out what to do.

Flash forward two months to now, the end of March: The United States has tested only 240,000 people. There is no nationwide random sample time series. An awful lot of symptomatic people were not tested, and were instead sent back into the community. By the metric of the speed of growth of reported cases since the establishment of the virus dated to the hundredth first-reported case, the U.S. has performed worst of any country: worse than Italy, worse than Spain, worse (we think) than Iran. The 35000 cases reported as of the morning of Mo Mar 23 are just the tip of the iceberg. From 500 currently recorded deaths so far in the United States, we might guess that there were between 15 and 50 thousand cases active at the start of March, which have grown to between 120 thousand and a million new cases coming in the next week. But we really do not know where we are.

Thus the United States right now has only one prudent alternative. Each day that the U.S. delays imposing the Wuhan lockdown makes future social distancing and quarantine measures that the U.S. might impose in the future less effective. The U.S. could roll the dice—President Trump and Treasury Secretary Mnuchin appear to want to—and make the bad-odds drawing-to-an-inside-straight existential bet that transmission will melt away with the coming of spring and the warming up of the country. That is more likely to lead the health-care treatment system to collapse and COVID-19 mortality spike from one in a hundred to one in twenty-five as 50 million symptomatic cases roll through America this spring.

But then, in three weeks, the lockdown can end. Public health can then do its normal job: testing a random sample, testing all those symptomatic, tracing contacts, and keeping the spread slow enough that the health care system is not overwhelmed and that the bulk of the cases come next year or the year after, by which time our virologists will have worked miracles.

And then, in a month, we are going to want to restart all the businesses that were functioning as of March 1. Nobody should go bankrupt as a result of anything that happened between March 1 and May 1 this year. That should be the proper goal of economic policy: to create a moment of Jubilee in the middle of this spring.

How would I do it, if I were running economic policy? Medical tests, treatment, tests, food, utilities, plus everything we can do that does not require human-to-human contact within six feet—that should be the extent of our economy for the next month. All else should be shut down. And then, in a month, everyone should go to the job they had on March 1. And if the financing isn't there to run your business on May 1—if you are bankrupt? That is what the Jubilee is for: the government assumes your debts. But what if people are worried about the now-higher government debt? That is good reason to impose a highly-progressive tax on income and wealth both to reassure investors that the long-term finances of the government are sound, and to recoup some of the unearned increment that will be captured over the next month by those who turn the lockdown into a source of financial advantage.

That is what the U.S. should do. That is not what the U.S. will do. For one thing, we do not have and are not making enough tests. And as of this morning, March 23, the Berkeley, CA hospitals are short of and asking for donations of surgical masks.