orgtheory.net

defense for the “open” position during covid

On Twitter, my good friend Mike Bader asked me if I still believed that “opening” is a good thing. My answer is yes. Roughly speaking, I believe that most institutions should try to resume normal operations and we should end most versions of the lock down.

In this post, I will explain my position in some detail. Here is the argument in brief, then I will explain the different parts below.

  1. Public policy should usually be focused on understanding trade offs and assessing risk. Totally eliminating a problem is often not technically viable or it has very large costs. Public policy should explore low cost partial solutions rather than seek perfect solutions.
  2. In understanding COVID risk, I focus less on case numbers, because they are ambiguous and there is a wide variation in terms of the impact on individual lives. Instead, I focus on mortality.
  3. We will likely have multiple waves of COVID if it is similar to other epidemics in US and world history.
  4. COVID is extremely dangerous for elderly people, but not for most other people. Deaths seem to be disproportionately concentrated in nursing homes.
  5. There are reasonable way to drastically reduce COVID transmission that do not entail more severe lockdown measures: remove people from nursing homes; wearing masks; avoid large gatherings.
  6. The level of COVID mortality is in the range of previous epidemics (except Spanish flu, which was way higher) and similar in magnitude to other risks that we already live with.

When you take these claims together,what you get is something close to the following position: 

  1. Focus on protecting the elderly by reducing their contact with the general population.
  2. Get people out of nursing home situations.
  3. Reduce the bunching up of people in space.
  4. If you need to bunch people together, wear masks. 
  5. Bunching people together is very low risk for young people and those in the middle of the life course.
  6. There will still be deaths, but they can spread over time (“flatten the curve). They will be mainly within certain sup groups, like the elderly.
  7. The level of mortality will be similar in order of magnitude to other things that we learn to manage, such as earlier epidemics, auto fatalities, hospital acquired infections, and mortality due to consumption of alcohol, tobacco, and narcotics.

For example, many people worry about school openings. However, as I will document below, mortality among minors for COVID is incredibly low. It would also be very low for parents without pre-existing health conditions. Thus the issue is whether asymptomatic children would infect elderly people at home. That is absolutely serious. But then you have multiple options: completely close schools/keep children at home OR allow exceptions, where some kids are taught remotely, or the elderly can be isolated. In other words, if you have a problem, you usually have multiple solutions, each of which has different trade offs. Shutting down schools indefinitely has costs: many parents may need to quit jobs to care for children; some families rely on schools for meals; and so forth. But if the risk is small for minors but large for the elderly, perhaps the better solution would be to re-open schools and then focus on the sub-population of students who have elderly family at home. If you can see the merit in that argument, you can start seeing the merit of the “open” position: focus on those at risk and encourage or require health behaviors in others. 

Below, I discuss the thinking behind points 1-6 that lead to an “open” position.

#1: You should manage most problems, not eliminate them: In general, you can’t make most problems completely disappear unless you have a big technical breakthrough that leads to a relatively cheap and easy solution. Why? Eliminating a problem completely is often a very expensive thing that has costs that people don’t want to bear. Here is a simple example. We could bring the number of homicides down to zero if we have a squad of police officers follow people around all day. Most people would not vote for such a solution. It would be horrendously expensive and it would end privacy. City budgets would be spent 100% on police and other services would be depleted. 

Similarly, we could eliminate COVID tomorrow – but it would be prohibitively expensive. For example, we could literally build each person a castle, pay for robot delivery of all services, and ban all human travel and contact. It would work, but it would be incredibly expensive in terms of money and it would essentially destroy the economy and our society – but it would work! The lesson is that there are serious trade offs to the “elimination” strategy that most people would not accept.

What is the position then? The answer is “manage until a cure or vaccine appears.” You have to sit down and really measure the extent of a problem and estimate the value of solutions. You have to sit down and ask what trade off do we normally accept in terms of managing risk and how does that apply to COVID.

#2: Focus on mortality more than diagnosed cases. Then, the starting point is to ask – what data is relevant to understanding how trade offs should be made? My argument is that mortality is more informative than raw cases. Hospitalization numbers are somewhere in between Why?

#3: There will likely be multiple waves of COVID. I am informed by two facts. First, most studies of US epidemics note that multiple waves happened in the Spanish flu, the 1957 Asian flu and the 1968 Hong Kong flu:

Also, we are now seeing a small uptick in COVID mortality. See the daily number of COVID deaths at NBC (https://www.nbcnews.com/health/health-news/coronavirus-deaths-united-states-each-day-2020-n1177936). It went down and is now moving up, as would be indicated if COVID was indeed similar to these earlier flus. Hopefully, it will be close to 1968 where it was “done” relatively early, but it is quite possible that it will occur again.

The point in focusing on this point is that an “open” position doesn’t mean that you don’t see risk. Rather, the risk is real and it is not easily avoidable but it’s about how to deal with it.

#4: COVID is very dangerous for elderly people, but not younger people. This also seems to be a consensus point among biomedical researchers. Early on, it was found that young people almost never died from COVID while elderly people were at high risk. The American Council of Science and Health has tallied recent research. What did they find? School age kids (5-14 in their chart) have a .013% chance of dying from COVID. That is literally 1% of 1% – and that’s assuming you have COVID. Let’s repeat: of every 1000 kids who get COVID,  less that’s 1 will die from COVID on average (https://www.acsh.org/news/2020/06/23/coronavirus-covid-deaths-us-age-race-14863)

In contrast, the story for the elderly is vastly different. It’s simply a disaster zone. The ACSH article reports that those around age 65 have a 20% chance of death. Let’s repeat: Of 1000 COVID infections in those age 65, 200 will die. In fact, the situation is so drastic that one writer argued that we actually have two epidemics: a relatively mild one for most people but another that is incredibly dangerous and it happens among the elderly, especially those in nursing homes. (https://www.aier.org/article/two-pandemics-one-serious-one-mild/)

#5: There are reasonable non-lockdown ways to drastically reduce transmission: The consensus seems to be that most COVID is transmitted via fluids in closed spaces. It is theoretically possible to transmit in other ways, but health agencies seem to backing off these are guides for practice. For example, the CDC backed off the view that surfaces are substantially transmitted of COVID. Specifically, they wrote “this [surface contacts] his isn’t thought to be the main way the virus spreads.”  (https://www.cdc.gov/media/releases/2020/s0522-cdc-updates-covid-transmission.html)

So what is the plan for reduction? Masks – they are the way that health care providers normally reduce transmission in clinical settings and they reduce transmission of fluids via coughing and sneezing. Even cheap cloth masks likely reduce transmission somewhat, though not nearly as much as those used in clinical settings. The other obvious thing to do is simply enforce spacing out, which most people already accept. 

The less obvious, but probably correct, strategy is to isolate the elderly. In most settings, this would simply entail making space for them if a family has the room, or eliminating contact with all others except family. Nursing homes probably need to do more. It makes sense that nursing homes are hotbeds of infection because of density. But spacing people out in nursing homes is probably not enough, people need to be moved out. Why? Nursing home residents come into lots of physical contact with health care providers, who need to help them with bodily functions and administration of medicines. In many settings, they also congregate closely. Considering that many residents have pre-existing health conditions, they are at very risk for COVID mortality.

#6: COVID is a level of risk that we have accepted before and where lockdowns were not used very much. Here, I’ll focus on the 1957 and 1968 epidemics. It is estimated that they killed 116,000 and 100,000 in the US. The population at those times were 172,000,000 and 200,000,000. The estimated pandemic mortality in the US was .0006% and .0005%. If we have 250,000 COVID mortalities in the 2020 calendar year, we will have a COVD mortality of .0007%. That is slightly higher than earlier pandemics where society was not shut down and people adopted more moderate measures (e.g., primary schools remained open but high schools shut down). 

Also, the US population seems to be willing to not “lock down’ for other risks. For example, at its peaks, about 100,000 people died from hospital acquired infections. And we recently had 40,000 auto fatalities in the US (See this earlier post: https://orgtheory.wordpress.com/2020/07/01/protest-covid-and-the-social-construction-of-risk/). The point is not to minimize these horrible deaths, but to point out that people seem to manage this risk rather that try to eliminate it (see point #1). We drive cars and go to hospitals, but try to do so in risk minimizing ways.

The bottom line here is subtle, but important: COVID is serious, but you can make a reasonable argument that we should focus on reducing transmission through mask use and spacing, focusing on high risk populations, and allowing other parts of society to resume something close to normal life.

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Written by fabiorojas

July 16, 2020 at 12:52 am

Posted in uncategorized

9 Responses

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  1. Yep. But you really have control or get cooperation with the mitigation practices or you end up like Miami or Houston.

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    Claude Fischer

    July 16, 2020 at 4:16 am

  2. Fabio, you raise several points, and I won’t be able to address them all. But I will note a few important places where I think the reasoning is off and thus the conclusion does not follow. [Apology in advance for the length of my reply]

    First, while I can understand your focus on mortality from a statistical point of view, i.e., those numbers are probably more solid than some alternatives, and it is clearly a meaningful phenomenon. However, I think it is just as important, if not more so, to focus on the post-COVID recovery experience. My understanding is that a lot of people recover, but never make it back to pre-illness levels. They have experienced abnormal electrocardiograms, heart damage, blood clotting, strokes, neurological damage, lung scarring, cognitive impairments, and lasting fatigue. As you reflect upon that list, keep in mind that we do not fully know the long-term implications of this illness. But, so far the evidence is not good. A lot of people may be willing to expose themself to the risk of death, even a reportedly difficult death, but be less willing to risk ending up with life-altering injuries. Your assessment focuses only on mortality, and in doing so basically completely ignores the many people who will never be the same. A lot of them are not elderly. They would have expected several more decades of life. Any assessment of COVID policy, I submit, has to go beyond mortality to consider the damage down to people’s later quality of life as well as their damage to people’s future ability to produce in the economy.

    Second, I presume you realize that there aren’t many people aware of the statistics on police brutality that would see your “way to eradicate homicide” as anything like a real policy option, nor what the policy would really mean if adopted. Yes, if we had angels as police officers, maybe it would work. We do not have an all-angel police force. In other words, there is no such policy option, so no one is really acting as if that kind of trade-off is even possible. That is not the case with COVID. We do know that we can stop the virus. Why? Because it has happened already. Look all around the world at the many countries that succeeded. They isolated, traced cases, tested widely, physical distanced, and wore masks. Federal politicians resisted wide testing; have not supported local efforts to test, trace, and isolate; and have actively undermined mask-wearing. This is a self-inflicted failure, not some non-negotiable fact of viral pandemics. Failure in the U.S. does not mean that we should resign ourselves to the “everything is okay” policies of the very people who blocked implementation of the same policies that led to success elsewhere. Yes, other countries’ success may be temporary. But it shows that even temporary success is possible, and if you do it right, it is a momentary blip, not a colossal economic and public health disaster. Other countries have shown they have the capacity to address such problems, together. The U.S. has not shown that capacity. Thus, we should not be so U.S.-centric when we evaluate policy options. And, I submit, the real problem is that as a nation the U.S. shows every sign of having lost its capacity to come together for the good of all in times of crisis. It is a major impediment.

    Finally, I believe your analogies with other risks, and how society has not locked down about them, are faulty. I ask, what would “lockdown” mean as a policy to deal with 100,000 fatalities from hospital infections? This is not something that occurs outside the confines of a hospital, so locking down society to stop it would make no difference. However, inside hospitals, it is arguably pretty much “lockdown” mode. Every hospital staffer has had their workflow altered by introduction of protocols to reduce HAI. They wash their hands between every patient. Visitors have also had their experience altered. That’s what lockdown looks like in that context. And, yeah, they did it, and we are the better for it. Visitors aren’t saying, “I’ll cough wherever I want.” And doctors and nurses aren’t throwing up their hands and saying, “Well, we just have to accept waves of HAI, and just try to test the people with diarrhea, that’s the best we can do.” And, no one is saying to anyone, “Get tough Grandma! HAI is just what it means to come to the hospital.” So, if this is your example of how society refuses to “lock down” in the face of risk, I think it is a good example, because it makes the entirely opposite point: When leaders look to the science, develop policies in line with the science, implement those, and refuse to accept any deviation from that policy, we can have a very successful “lockdown”-like policy which saves both lives and quality of life. In many other countries that’s what leaders did. But not here.

    Liked by 2 people

    Sam Lucas

    July 16, 2020 at 6:34 am

  3. Your most bizarre, irresponsible contrarian post I’ve ever read–and that’s saying a lot.

    Liked by 1 person

    nope

    July 16, 2020 at 12:43 pm

  4. With an R0 and the prevalence at the current level, the virus cannot be contained to subgroups. This is not a regression analysis, there is far too much movement, and too little is known about the long-run effects. Instead, we should be pouring resources into vaccines, public messaging around masks and quarantine protocol. Of course, as I have argued for a decade, since graduate school, and been largely ignored and ridiculed, there is intense polarization around knowledge production and cultural dissemination (the cultural war is about who you trust). So, you also need to identify messaging tech that can reach specific groups with messages tailored to their dispositions toward science, political orientation, and education etc.

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    gwg

    July 16, 2020 at 4:32 pm

  5. perceptions of science and credibility do matter.

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    gwg

    July 16, 2020 at 4:33 pm

  6. also, Fabio, this is just a prelude to climate change, so we should practice what it looks like to mobilize the globe around the survival of the planet (species) rather than profit. It is difficult, I know, but the choices are pretty stark. I feel like I’m looking over the Trenches and its 1917 and my superior officers are rearranging the bunker furniture.

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    gwg

    July 16, 2020 at 4:40 pm

  7. This response seems to entirely ignore the reality of the disease. I guess you are lucky to have been spared the knowledge that we in places that have been dealing with high case rates for many months now have, but this isn’t a disease where some old people die and others get better in a couple of weeks. Many people will survive but with permanent disabilities, needing lung transplants if they want to continue to live. Many people are sick for 2, 3, or more months. Many have permanent cardiac disability and will never be able to resume their prior activity levels. And we don’t yet know what kind of long-term effects even survivors who seem not badly impacted will experience–think about shingles as a consequence of chicken pox, for example.

    The evidence I have seen suggests that opening K-5 schools might be lower-risk, but only in the context of serious commitment to avoiding community spread (e.g. keeping bars and indoor dining closed), with appropriate masking of adults, reductions in class size, and other (expensive) mitigation measures. Teenagers and young adults, however, are especially likely to spread the disease. And if you could bunch them together in their own bubble where they only impacted themselves, you might have a point. But this is impossible. High school and college students will infect their parents, grandparents, teachers, coaches, etc. and will carry disease to surrounding communities.

    Masking, of course, would be very helpful, IF WE LIVED IN A SOCIETY IN WHICH PEOPLE WORE MASKS. But there are businesses that have had to shut themselves down because customers refuse to comply with basic requirements for safety. There are states forbidding local masking ordinances. So just pointing to masks as a solution is woefully ignorant of the reality of this country.

    And if this hasn’t occurred to you: a very large percentage of educational facilities are built with ventilation systems that are inappropriate for the age of COVID, especially with unfiltered recirculating HVAC and inoperable windows. It is likely that these systems will considerably exacerbate spread, as some evidence from South Korean officebuildings suggests.

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    Mikaila

    July 19, 2020 at 11:29 pm

  8. Good article and mostly agree but I think there is a numerical mistake here:

    “The ACSH article reports that those around age 65 have a 20% chance of death.”

    I think this sentence is a misinterpretation of table 1 on https://www.acsh.org/news/2020/06/23/coronavirus-covid-deaths-us-age-race-14863. Table 1 lists (# in age group died) / (total # died), not (# in age group died) / (# infected in age group). Notice how the last row, “All Ages”, is 100% – certainly the all-ages mortality rate for infected people is not 100%!

    Googling around a couple places now, I see estimates of the death rate of COVID-infected persons ranging from 4% to 10.5%. The final table on the ACSH page lists a Swiss estimate of the Infection Fatality Rate in people 65+: 5.6%, much lower than 20%.

    Like

    Maxwell

    July 28, 2020 at 2:24 am

  9. Forgive the double comment but I just noticed: if I am right about the interpretation of the ACSH table, this part is incorrect for the same reason:

    “The American Council of Science and Health has tallied recent research. What did they find? School age kids (5-14 in their chart) have a .013% chance of dying from COVID. That is literally 1% of 1% – and that’s assuming you have COVID. Let’s repeat: of every 1000 kids who get COVID, less that’s 1 will die from COVID on average”

    Like

    maxwell7886

    July 28, 2020 at 2:27 am


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