“America will again, and soon, be open for business,” President Donald Trump said on Monday. “Very soon. A lot sooner than three or four months that somebody was suggesting. A lot sooner. We cannot let the cure be worse than the problem itself.”
The cure, in this case, is social distancing, and the mass economic stoppage it forces. The problem is Covid-19, and the millions of deaths it could cause. On Tuesday, Trump accelerated his timeline. He said he’d like to see normalcy return by Easter Sunday, which is April 12. “Wouldn’t it be great to have all the churches full?” he asked. “You’ll have packed churches all over our country.”
Public health experts reacted with horror. But the question Trump is posing needs to be taken seriously. The costs of social distancing are tremendous. The economic forecasts now predict a GDP drop and an unemployment rate of Great Depression-level proportions. The human suffering that will be unleashed is real, and it is vicious.
It feels cold and inhuman to ask the question: “How many lives is economic growth worth?” But we ask — and answer — it constantly, even if we rarely admit it. Millions die from pollution and car accidents, byproducts of our industrial economy and transportation networks. We could close the factories, block the roads, and save those lives. But we don’t. As Trump often points out, tens of thousands die each year of the flu, but California doesn’t shutter its restaurants.
Moreover, mass economic suffering poses its own dangers, both physical and political. “Right now, people are stunned by what is happening,” Frances Lee, a political scientist at the University of Maryland, wrote to me in an email. “But they will wake up soon and realize that they have been ruined economically.” When that happens, she worries, it will be “a profound threat to social peace.” Epidemiological models forecast the path of disease, not the stability of societies. Add that into the model and perhaps the cost-benefit analysis changes.
Lurking at the center of this debate is an imagined world where we let Covid-19 rip through the population, killing millions and hospitalizing far more, but younger, healthier Americans keep the economy humming along as normal. “Let’s get back to work, let’s get back to living,” said Texas’s Republican Lt. Gov. Dan Patrick. “Let’s be smart about it. Those of us who’re 70-plus, we’ll take care of ourselves. But don’t sacrifice the country.”
But many — myself included — question whether that’s realistic. As Bill Gates put it, “it’s very tough to say to people, ‘Hey, keep going to restaurants, go buy new houses, ignore that pile of bodies over in the corner. We want you to keep spending because there’s maybe a politician who thinks GDP growth is all that counts.’”
The thinking being framed here as a grim acceptance of the economy’s primacy is questioned by top economists as both morally and empirically misguided.
“Look, I’m an economist and I am gruesomely comfortable with putting a value on a life,” says Jason Furman, who teaches economic policy at Harvard’s Kennedy School of Government and served as chair of the White House Council of Economic Advisers under Obama. “If it costs one hundred million dollars to save a life, and we have a limited budget, it may not be not worth it. But I think the right model right now isn’t that you’re trading lives off against better economic performance. It’s that if you don’t save those lives, you might have even worse economic performance.”
The true choice, Furman argues, is this: You can suppress the virus now and deal with a terrible economy six months from now, or you can wait two more months to suppress the virus, find yourself forced into yet more extreme quarantine measures because the virus is pervasive and the death toll overwhelming, and find yourself in an even more horrendous economy on the other side.
Before we pit economic growth against human life, in other words, we need to be sure whether that’s truly the choice we’re facing. “We’re not necessarily having a moral disagreement,” says Ruth Faden, the founder of Johns Hopkins Berman Institute of Bioethics. “If you’ve got very different empirical views of how this is going to play out, what looks like a moral disagreement ends up being a disagreement about probabilities and contingencies.”
This is a debate worth having, but it needs to be had with a lot more clarity, and a lot more rigor. So let’s have it.
Imagining the unimaginable
On Tuesday, the World Health Organization warned that America was becoming the new epicenter of the pandemic. If you plot new cases in the US against the path the disease has followed in other countries, we’re on track for the worst Covid-19 outbreak in the world.
Responsible epidemiologists will tell you not to extrapolate crudely: When caseloads rise rapidly, societies respond, imposing harsh social distancing measures to slow the spread of the disease. That’s how the curves bent in other nations, they say, and it’s how it’ll bend in America, too.
But America, unusually, is led by a president advocating the opposite: Caseloads are rocketing upward, and he wants to pull back on suppression measures within two weeks.
Imagine if we did. On April 12, the Trump administration, as well as every state and locality, lifts the social distancing guidelines. Restaurants reopen. Church pews are packed. Bars throw “F the coronavirus” parties. The virus accelerates. Hospitals are quickly overwhelmed — which means the virus becomes more lethal, as people who need ventilators can’t get them. But it’s not just the virus that becomes more lethal. All medical emergencies become more lethal, because the ICUs are packed and there are critical shortages of doctors and nurses.
In a scenario like that, it’s entirely possible that the coronavirus would infect 60 percent of the country, with a case fatality rate of 1.5 percent, in a matter of months. That would mean almost 3 million deaths directly from coronavirus — roughly three times as many Americans as have died in every war we’ve ever fought combined. And that doesn’t count the deaths indirectly caused by coronavirus. With hospitals in lockdown, people would cease seeking care for chest pain, they’d put off needed surgeries, they’d try to treat at home what they would once have asked a doctor to diagnose. Many of them would die.
I have focused here on deaths, but suffering matters, too. As Scott Gottlieb, Donald Trump’s former Food and Drug Administration commissioner, notes, Covid-19 is a brutal illness that forces hospitalization and even ICU admission in a large proportion of cases, even among the young.
While vast majority of deaths from #COVID19 are age 60+ many young adults and middle aged Americans are becoming seriously ill and surviving only after prolonged hospitalizations and ICU admissions that have long term consequences. This is a dangerous virus for most age groups. pic.twitter.com/jVYWFatTDM
— Scott Gottlieb, MD (@ScottGottliebMD) March 23, 2020
It’s absurd to think that Americans under age 65 would go about their lives as normal, risking a disease that could force them into the ICU when the ICUs are full. And what about those of us who have immunosuppressed partners, or who want to visit our parents?
This is why so many economists are skeptical of arguments that pit the economy against the virus. They worry that if you let the virus rage unchecked, you’ll get both a worse epidemic and a worse economy.
On Thursday, a group of economic luminaries, including the past two Federal Reserve chairs, and chief economists and Treasury secretaries from both Democratic and Republican administrations, released a letter arguing that the path back to a functional economy runs through sound public health measures. “Saving lives and saving the economy are not in conflict right now; we will hasten the return to robust economic activity by taking steps to stem the spread of the virus and save lives,” they wrote.
New research offers historical support for that argument. Economists Sergio Correia, Stephan Luck, and Emil Verner looked at the areas of the United States that were hit hardest by the 1918 Spanish flu pandemic. The cities that deployed social distancing measures earliest and most aggressively fared better, on both health and economic measures, than the cities with slower, weaker responses. Social distancing interventions, the authors conclude, “can reduce mortality while at the same time being economically beneficial.”
There is an aesthetic of toughness to making the argument, right now, that we could keep calm and carry on in the face of an unchecked plague. But if you force yourself to imagine that world deeply, the counterfactual breaks down. There’s no normal economy, or normal polity, amid that kind of mass death. “It’s an unreal realism,” says Adam Tooze, an economic historian at Columbia University who studies financial crises. “In practice, what that will do is create such a catastrophic collapse in employment and business activity that it will be completely untenable as an economic policy or politically.”
Trump is making this argument now, when the economic and political pain of social distancing is present but the horror of 20 million coronavirus infections isn’t. As Sen. Lindsey Graham (R-SC) put it, “Try running an economy with major hospitals overflowing, doctors and nurses forced to stop treating some because they can’t help all, and every moment of gut-wrenching medical chaos being played out in our living rooms, on TV, on social media, and shown all around the world. There is no functioning economy unless we control the virus.”
What’s the social distancing endgame?
If the leading voices in the “carry-on” crowd have offered a false choice, part of the reason it’s taken hold is that the social distancing crowd has, too often, offered no choice at all.
I live in the Bay Area, in northern California. We were the first locality to impose shelter-in-place rules. Those rules — their severity and their urgency — were clearly communicated. But despite closely following the news, I have no idea what is supposed to happen on April 7, when the order ends. Will it be renewed? Did we use this time to radically increase the number of hospital beds and ventilators? Do we have the capacity for mass testing, such that we can move toward something like the models we see in Taiwan or South Korea?
Social distancing itself is not a cure. This becomes sharply clear in the influential Imperial College report modeling different paths for the outbreak (with added commentary here). Yes, social distancing works to slow transmission. But the disease roars back when the restrictions ease. “This type of intensive intervention package — or something equivalently effective at reducing transmission — will need to be maintained until a vaccine becomes available (potentially 18 months or more) — given that we predict that transmission will quickly rebound if interventions are relaxed,” the authors write.
So let’s put this clearly: Comparing the cure and the disease is a false choice in both directions. If you let the disease rage, you don’t save the economy. But if you lock down the economy, you don’t cure the disease. It is understandable, in the initial panic to slow the disease, that public health messaging has emphasized the importance of social distancing, but in order to keep people bought into that strategy, it’s necessary to be clear about what comes after.
Extreme social distancing measures buy time. That’s time that needs to be used for four things: Bringing the disease’s reproduction rate down so the caseloads begin to fall. Surging health supply to handle the infections we already have and currently expect. Massively expanding testing capacity so we can track the disease going forward. And passing enough support and stimulus measures so people can survive this period economically, not just epidemiologically.
Together, these policies could, as the Center on Global Development’s Jeremy Konyndyk told Vox, move us from “sledgehammer” to “scalpel.” Or, as entrepreneur Tomas Pueyo has put it in a viral series of Medium posts, “the hammer and the dance”:
If that’s done well, we could move toward a phase more like what we see in Taiwan: constant vigilance and large-scale testing, the reimposition of social distancing if cases get out of hand, but normalcy most of the time, for most of the population.
That is not a sunny vision of our immediate future, but these are not sunny times. “This is one of the most significant crises that the world has ever faced in terms of the numbers of lives that could be lost and the destruction to the economies globally and nationally that will result,” says Faden. We will not escape it unscathed, and no one should pretend otherwise. But the choices we make in the coming days will decide whether it is difficult or disastrous.
The grim truth, for those of us living under tight lockdowns right now, is it’s not clear that the time we’ve bought is being used well. Social distancing is likely slowing disease transmission, but there’s little evidence that the country has been sufficiently swift in surging health and testing capacity. Indeed, governors of key states are saying, daily, that they’re not getting the support they need.
Since the beginning I’ve promised you transparency and honesty on all aspects of our response.
To that end, I want to take a moment now to run you through our PPE requests with the federal government, and what we’ve received from them. pic.twitter.com/SsOw1l4UKF
— Governor JB Pritzker (@GovPritzker) March 23, 2020
Konyndyk says we need a “Manhattan Project effort to get this stuff in place in really a two-or three-month period.” So far, we aren’t seeing one.
This is where presidential leadership really matters. If Trump had put the full weight of his presidency, and of the federal government, behind a well-sequenced coronavirus response plan, the country could understand what their sacrifice was being used for and feel confident that there was an endgame.
Instead, the opposite is happening. Trump spent a couple of days acting like the president, but he quickly reverted to his more traditional behavior of hammering his enemies and blaming the media for his problems.
The LameStream Media is the dominant force in trying to get me to keep our Country closed as long as possible in the hope that it will be detrimental to my election success. The real people want to get back to work ASAP. We will be stronger than ever before!
— Donald J. Trump (@realDonaldTrump) March 25, 2020
That most every affected country in the world either reacted more swiftly than America, or has imposed more aggressive social distancing, makes clear how dangerous it is for Trump to treat public health recommendations like a conspiracy against his reelection campaign. Israelis, for instance, are being told to stay within 100 yards of their homes or face fines or even imprisonment. Does Trump believe that’s because Benjamin Netanyahu is watching too much MSNBC?
Rather than make the country’s sacrifices count, Trump is telling Americans we’ve already sacrificed too much, for too long. This is a moment that demands social solidarity, but all Trump knows is fracture. This is a moment that requires long-term thinking and sacrifice, but Trump acts on the timeline of the cable news segment in front of him. It is perhaps the most stunning and dangerous abdication of presidential leadership in the modern era.
“When the president stands on top of a table and says, ‘This is super important, super urgent, everyone must do this,’ the government works moderately effectively,” says Ron Klain, who managed the Obama administration’s Ebola response. “That’s the best case. When the president is standing up and saying, ‘I don’t want to hear about it. I don’t want to know about it, this doesn’t really exist,’ well, then you’re definitely not going to get effective work from the government.”
An irony of the coronavirus crisis is that if we managed it well, it would likely feel to the public that the sacrifice wasn’t worth it. Politicians don’t get credit for the lives they saved, for the catastrophes they averted, but they do get punished for the pain they cause. An ideal response would make the cost of disease suppression visible even as it lured people into a false sense that the virus’s threat was overstated. As Dr. Anthony Fauci, head of the National Institute for Allergy and Infectious Diseases, put it, “if it looks like you’re overreacting, you’re probably doing the right thing.”
But what we are barreling toward right now is much worse: an inept, fumbling response in which we fully experience the virus’s toll — in which millions die and the economy freezes and we find ourselves dearly wishing we had understood the choices better, and made the hard decisions earlier.
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Slowing coronavirus will impose real costs, and immense suffering, on society. Are those costs worth it? This is the most important public policy question right now. And if the discussion isn’t had well, then it will be had, as we’re already seeing, poorly, and dangerously.
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