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Perhaps the most frustrating aspect of the COVID-19 pandemic is reading about non-pharmaceutical interventions (NPI) like social distancing, stay-at-home orders, and business closures have saved lives. They have not done so. NPI merely delay cases, and potentially deaths, not prevent them from ever occurring in the way a vaccine or cure would. Flattening the curve only prevents excess deaths from the health care system being overwhelmed. A three month or three year lock down does not alter Americans’ vulnerability to a new and sometimes deadly virus.
Epidemiological models divide the population into three groups, susceptible, infected, and recovered (with a fourth perhaps for deceased). With any brand new virus like SARS-CoV-2, everyone is initially susceptible. Once a virus is widespread, NPI merely keep people in the susceptible bin; for viruses with very limited outbreaks like SARS and MERS, NPI can suppress and basically eradicate the virus. An effective treatment ensures everyone in the infected bin makes it to the recovered bin, while a vaccine moves people from susceptible directly to recovered.
As individuals and through our local, state and national governments, we must decide how to address our susceptibility. There are 330 million Americans. Suppose everyone catches SARS-CoV-2 over the next few years. The CDC currently estimates that 40% of infections are asymptomatic and that the overall infection fatality rate is 0.65%. Moving all 330 million Americans to the infected bin would result in about 200 million symptomatic cases and perhaps 2 million deaths. Our goal should be to minimize the costs to society of the new virus. Can we do better than this? Might we do worse?
Our government leaders and public health officials have not articulated how NPI fit into a larger plan. NPI are a delaying action and are extremely costly, both economically and by infringing on Americans’ freedom. NPI must be part of a larger plan to truly save lives and potentially be worthwhile policies. I see three ways NPI could reduce deaths, assuming that the policies are indeed effective at stemming transmission. I will not evaluate the different plans here. A larger plan is relevant for both the SARS-CoV-2 pandemic and future pandemics.
Flattening the Curve to Avoid Excess Deaths
“Flattening the curve” to prevent the overwhelming of the health care system has become part of our lexicon. The worst-case pandemic scenarios which provoked the lock down did not estimate excess deaths due to an unrestrained pandemic. Extra deaths beyond the 0.65% infection fatality rate would occur if every patient did not receive the highest quality of care possible.
The nature and number of excess deaths depend on the actions taken. For example, if COVID-19 patients were turned away from overcrowded hospitals or not ventilated,, the excess deaths would be from COVID-19. One projection of a worst-case pandemic assumed that half of patients needing ventilators would die, implying that the COVID-19 fatality rate might double when the health care system is overwhelmed. If COVID-19 patients displaced other patients, as happened through elective surgery bans to keep hospital beds open, the excess deaths might be cancer patients unable to receive treatments.
A delaying action buys time, which will be valuable for an unexpected pandemic or new virus. The capacity of the health care system can be increased through temporary hospitals and added ICU beds, protective equipment and medicines could be stockpiled. For a new virus, doctors will learn more effective ways of treating patients. Existing antivirals and other medicines can be tested for effectiveness. American doctors have treated hundreds of thousands of serious cases, and lessons have been learned, albeit unfortunately with significant loss of life. Serious cases in July 2020 will get treated based on the knowledge gained. This could save thousands of lives even without a cure or vaccine.
Wait for a Vaccine or Cure
The most valuable forms of knowledge for a new virus would be a vaccine or cure (or highly effective treatment). This is the most effective way to avoid a potential 2 million deaths possible from moving all Americans from the susceptible to recovered bins.
The economic and social costs of the lockdowns of Spring 2020, before being relaxed have been estimated at $1 trillion per month. Most viruses do not have either a vaccine or an effective treatment. Waiting as a plan must involve a clear expectation of expedited development, approval, and production of a vaccine or treatment. The development component involves knowledge production, and is the biggest unknown in this process. Both science and economics are discovery processes and one can never know ahead of time what will be discovered. Still, by the end of June an estimated 168 candidate vaccines for SARS-CoV-2 are in development with 14 in human trials. This was a brand new virus whose DNA was first identified in early January, not a new strain of influenza where the existing flu vaccine can be tweaked. We may have sufficient knowledge of medicine and biology to make sheltering for a vaccine or cure a potential option.
Securing regulatory approval comprises most of the 18 to 24 month time frame often repeated for a potential COVID-19 vaccine. The regulatory approval process is a policy choice we impose upon ourselves. We can craft an expedited approval process for during a pandemic, hopefully relying on human challenge testing, and learn if a candidate vaccine is safe and effective within three months of delivery.
The biggest practical problem in a “wait for a cure” plan is determining whether prospects are strong enough to make waiting worthwhile, or when we need recognize a cure or vaccine is not going to happen. Hope springs eternal and we might always think a cure or vaccine is just around the corner. The desirability of hunkering down for a vaccine or cure will likely vary across viruses based on ease of transmission and lethality.
Protect the Vulnerable Population
The risk of death from COVID-19 is highly focused on certain vulnerable populations, commonly described as elderly and those with preexisiting conditions. The potential exists to use NPI to protect the vulnerable while allowing the SARS-CoV-2 virus to circulate through the population. This strategy would not be possible for a virus without a high risk population.
To see how this strategy addresses the universal vulnerability to a new virus, imagine that we could identify all of the vulnerable and safely isolate them. The virus could circulate through the low risk population, moving them to the recovered bin with no loss of life. When the vulnerable emerge from isolation, the virus will no longer be circulating. This is essentially what widespread vaccination accomplishes for individuals who cannot be vaccinated.
The effectiveness of the strategy would depend on how precisely the vulnerable can be identified ex ante, the number of persons needing sheltering, and the duration of sheltering. If the 2 million Americans who would die if they contracted COVID-19 could be identified – admittedly impossible – and perfectly protected, we could avoid all deaths and at a limited cost. The vulnerable population undoubtedly would be much larger. The Kaiser Family Foundation estimates 41 million Americans under the age of 65 are at risk for COVID-19 due to health conditions, plus 51 million persons over age 65. Imperfect protection would result in some of the vulnerable becoming sick. The length of time the vulnerable would need to shelter is relevant as well; the quicker the virus spreads through the healthy population, the lower the cost of sheltering the vulnerable.
Implementing a protect the vulnerable strategy will require time for preparations like stocking up on supplies and protective equipment and identifying staff willing to lock down with patients. Preparations will likely be more extensive the more effective protection we hope to implement. A preliminary society-wide lockdown may be needed to protect the vulnerable.
Is a Plan Really Necessary?
Economists trained in the spontaneous order tradition of Adam Smith, Ludwig von Mises, and Friedrich Hayek will object that the government planning is not necessary. We could instead rely on the rational self-interest of people and organizations and the resulting social learning. The absence of a government plan is not an absence of planning but instead a plethora of individual plans. I count myself as a spontaneous order economist, so I wholeheartedly agree.
Still government action to slow the spread of an infectious degree may be an exchange of constraints in James Buchanan’s approach to constitutional political economy, one which many citizens may willingly accept. In any event, school and business closures and stay-at-home orders now form part of our economy’s institutional framework. Whether the lock downs were worth the cost is and will remain controversial, and people may reasonably disagree on this. Epidemiological models clearly show that NPI do not eliminate a virus once it is sufficiently prevalent in the environment. SARS-CoV-2 will be out there whenever the lock downs are relaxed. Consequently NPI can only truly prevent deaths long term when part of a larger plan. Our politicians and public health officials have still not articulated a plan or gotten our consent for it.