Good afternoon,
The Covid-19 virus will be a major factor in our lives for at least 18 more months. At that point it is possible that some combination of a widely available vaccine, herd immunity, or a change in the virulence of the disease will have brought significant relief. None of these is by any means certain, and the chances that any of them will have a broad effect in less than 18 months is slim. But they are the only ways we will escape this crisis.
Therefore, the only wise path, individually and collectively, is to plan our lives on the assumption that we will be dealing with this pandemic for at least 18 more months – basically through the end of 2021. Again, there is no guarantee that significant relief will be at hand by then, but at least there is reason to hope this might be the case. In the meantime, let us think about how we will live our lives for the next 18 months.
To achieve the best possible outcome, we must find a wise balance between many different factors, as opposed to the compartmentalized thinking that has characterized so much of our response so far. We must use common sense, as opposed to embracing easy solutions, taking rigid positions, or surrendering judgment to the groups that are turning this crisis into a partisan conflict.
Learning from the past
Covid-19 is a dangerous disease, and deadly. It is imperative that we try to limit its effects. In past essays I enumerated various steps needed to accomplish this goal. At the same time, it is crucial that we understand the difference between the harm caused by the disease itself versus the harm caused by excessive efforts to prevent it. The first principal of medicine, as articulated by Hippocrates almost 2500 years ago was: “Do no harm.” We must take this admonition to heart and pay careful attention to the dangers that any steps we take to fight Covid-19 will pose. All our mitigation efforts are a choice, so we must choose wisely, being especially mindful of the potential for unintended consequences. An excellent way to understand this is to look at the history of the last similar pandemic on our shores, the Hong Kong flu of 1968 and 1969.
If you are old enough to remember those years, did you shelter-in-place for months at a time? Were millions of businesses closed down? Did a third of the labor force lose their jobs? Did you wear a mask when you went out in public? I remember those years well, yet I was not aware at the time that 100,000 people were dying in the U.S. from the pandemic caused by the Hong Kong flu. (That would be equal to about 167,000 dying in 2020, in terms of the percentage of the population. As many as 4 million died worldwide in that pandemic – as a percentage of the population that would be equivalent to almost 7 million today.)
In 1968 I spent a good bit of time in New York City, working in the presidential campaign of that year, and I traveled frequently throughout the year. During 1969 I continued travelling, often on packed airplanes. I heard people mention the Hong Kong flu, but paid little attention. I do not remember anyone sheltering-in-place or wearing masks.
On the economic front, throughout 1968 and into early 1969, GDP in the US was expanding at around a 5% pace, and the unemployment rate was very low. The economy was, in fact, so strong during the Hong Kong flu pandemic that the Federal Reserve began a series of interest rate hikes in early 1969, and the federal government instituted a series of tax hikes in 1968-69 – including a 10% surcharge on individual income taxes, increased telephone and automobile excise taxes, and increased social security payroll taxes. (For the calendar year 1969, this fiscal tightening amounted to around 3.75% of GDP, which brought the economic expansion to an end in the later part of 1969.) Now, think of the contrast with 2020, during which there have been massive actions in the opposite direction – lowering taxes and raising interest rates in an attempt to save the economy from collapse. And in the process creating the greatest financial deficit this country has ever known.
In sum, the economy was not hurt by the pandemic of 1968-69. Jobs were not lost; people were not going hungry because of the disease. The devastating effects we are suffering today in the U.S. and all over the world were not experienced in 1968.-69 – which makes vivid that the economic costs we are undergoing today are due to our reactions to the pandemic of 2020 – as opposed to the effects of the disease itself.
This is not to say that measures to limit the spread of Covid-19 should not have been taken. Nor that further measures should not be taken now. This history is simply to point to the importance of finding the right balance between helping the most people continue their lives and livelihoods while simultaneously finding wise methods to limit the spread of the disease. The lesson is not to ignore the pandemic, as was mostly done during 1968-69. Lives could have been saved back then. At the same time, few lives were lost because of an overreaction to the disease in those years. There was not mass starvation, or job loss, or economic collapse. The lesson is to find the right balance between ignoring and overreacting. Covid-19 will be with us for a long time, so we must find ways to live with it that are not organized around closing down and fear. We can take more actions than were taken in 1968-69 to prevent the spread of disease – without overreacting – if we keep firmly in mind that overreaction itself can cause much harm.
A false opposition
One overreaction is to frame the decisions we are making as between saving lives and saving the economy. This is a totally false idea. The two cannot be separated. The disease is taking many lives around the world right now, but the actions we are taking to slow down the disease are costing many lives as well. The issue is not about saving jobs versus saving lives, but about the painful trade-offs we must consider, the choices necessary between actions to stem the disease versus the harm those actions will cause.
And this is why we must focus on the time-frame of at least 18 months. The longer restrictions on commerce, travel, and normal societal functioning continue, the more lives that will be lost due to the collapse of livelihoods, the breakdown of systems of living, and the feelings of frustration, anger, loneliness, and anxiety that are sweeping the world. Sadly, actions to stem Covid-19 around the world to date could end up costing millions of lives due to starvation, disease, and despair. The chief economist at the United Nations World Food Program recently estimated that the disruptions imposed by the pandemic could drive an additional 130 million people in the world, many of them children, into acute hunger by December of this year.
Just in the United Sates, who could have imagined a few months ago that food banks would be overwhelmed by desperate people all over the country? In early May it was estimated that one-fourth the citizens of New York were facing food insecurity, which is 2 million people in New York alone. A Brookings Institution study found that one in six young children in the U.S. were not getting enough to eat in mid-May. Try to imagine, then, what must be happening in the slums of India, Bangladesh, Brazil, Nigeria, and on and on.
These numbers make vivid another crucial point: the burden of this pandemic and our reaction to it are not falling equally on everyone, but hitting most dramatically the poor, the marginalized, those already living in difficult circumstances. More than half of American households in the lower income brackets now include a person who has lost a job. By the first week in June, over 42 million people had filed for unemployment. Let that number sink in – 42 million people had officially had to file for unemployment as of the start of June, 2020. While some of those people are slowly going back to work, it will be a long, long time before they all return – if ever. And 42 million is only the official number. Additionally, many states have not caught up with claims filed, and in other states many laid-off workers have not yet applied for benefits for a variety of reasons, such as pride about saying they are unemployed, moving to another state to live with family (if you recently moved into a state you cannot file), confusion about the process, etc. Another group of people have simply left the labor force entirely, and thus have not applied for unemployment.
Finally, several million people laid off or facing reduced hours are not officially considered unemployed by the Bureau of Labor Statistics because they are not actively looking for work or do not meet traditional BLS criteria for unemployment. This is the Catch-22 of this extraordinary moment; you can’t look for work if you are ordered to stay home and businesses are shuttered, but you can’t be counted as unemployed if you are not looking for work. A good estimate is that there are an additional 20 million people beyond that 42 million number who have had to stop working because of the shutdowns around the pandemic.
There are other casualties. New high school and college graduates who would have been entering the labor force in June are having a terrible time looking for work, and there will be few new jobs for them in the coming months. Then there are the millions of undocumented workers who have lost their jobs: they will never be eligible for unemployment benefits, and so they and their families will suffer the most severe losses of all. On top of all this, there are several million people who have not yet lost their jobs (including a significant number in the middle and upper salary ranges), but who will, as the full effects of the recession we are entering washes over us.
All told, then, there might be as many as 60 million people in the U.S. alone who have to deal with some form of unemployment, over one-third of the labor force, because of actions taken by local, state, and the federal government to prevent the spread of Covid-19. A lot of those jobs will come back, but many will not. We are barely beginning to see the true size of the devastation, which is not only economic but psychological as well. One study suggested that it takes longer to adapt to the pain of losing your job than to losing a loved one. It is impossible to compare these things, of course, but the point is that losing a job is often a devastating blow to one’s life. For this reason, almost every developed country in the world has made a major effort during this pandemic to keep people on payrolls. Unfortunately, in the U.S. we made a terrible botch of this, far worse than almost any other developed country.
Looking at all this in relation to 1968-69, it becomes clear that job losses have not been caused by the disease itself, but by our attempts to mitigate it. And sadly, many of these actions were taken under the misguided assumption that the pandemic would be over in a month or two, and that things would then get back to normal. This was wishful thinking. Now, as more and more people accept what should have been obvious in March – that this pandemic will be with us until at least the end of 2021 – what will we do about all those lost jobs? Millions of workers in the restaurant, airline, and travel industries that were ordered closed will never return to work, or at least for many years. Many small businesses will be filing for bankruptcy. The U.S. Chamber of Commerce has said that more than 40 percent of the nation’s 30 million small businesses could close permanently in the next six months. “It’s a crisis that will impact our economy for generations,” said Amanda Ballantyne, executive director of Main Street Alliance, an advocacy group for small business. “We’re going to lose so much of the small-business sector.”
Especially hard hit has been the Black middle class, with hundreds of thousands of businesses going under. The number of working black business owners has fallen 41 percent since February. Another estimate suggests that nearly half of Black businesses are mothballed, for they were disproportionately in sectors of the economy worst-hit by closures – hair and nail salons, taxis, restaurants, daycare centers. Many of them will never come back, They have also had more difficulty accessing government aid, the great majority of which has been claimed by larger businesses that had staff trained in dealing with government applications.
The devastation wrecked by closures all over the country goes on and on. Most shopping malls were closed, and many will not come back. Nor will the many small retail stores that were surviving month to month. And the fear used to keep people at home has taken a fierce toll on the revenue of millions of health care providers, as well as hospitals and clinics. Visits to hospital emergency departments are down by as much as 40 percent, dentists have had an almost complete loss of income – as have physical therapists, massage therapists, and many other providers. Even many doctors have seen their patient visits cut in half or more, because people are afraid to go to medical establishments. There will be a large price paid.
Another area of concern that is just emerging is that the closures are beginning to take a terrible toll on tax collections – just as expenditures to meet unemployment benefits and many other demands are sky-rocketing. The impact of this is just beginning, especially because almost all state and local budgets must be balanced, and there will be a shortfall of hundreds of billions of dollars of revenue in the next couple of years. This will mean that as many as 4 million state and local jobs will be eliminated in the coming months, unless a federal aid package saves them in the near future (which is looking less and less likely).
The depressing litany continues. Because of layoffs, 30 to 40 million Americans are at risk of losing employer-sponsored health insurance, and many of them don’t have any short-term prospect of replacing it. More than one-fifth of Americans said they had little or no confidence in their ability to pay next month’s rent or mortgage on time. Tens of thousands of non-profit organizations are seeing their incomes drop substantially, and several million jobs could be lost in the non-profit sector. And, although it might be a positive factor in the long-term, many people who do keep their jobs will increase their savings in reaction to the difficult financial times, which will negatively impact the economy in the next year or two.
Again, none of this is to say we should not have taken steps to stop the spread of Covid-19, nor that we should not take other steps now. If there is an intense outbreak in a specific locale, dramatic steps are needed. The above points are to make as clear as possible that we have to search for the right balance between saving lives and saving jobs, rather than thinking of these two things in opposition to each other. To think of these two as opposed is dangerous, and will cost many lives, depending on the direction in which we err.
And as we grapple with the best path forward, we must constantly keep in mind that, although a few people in the world have the luxury and financial resources to stay in a protected environment for the next 18 months, they can do so only because many, many others are willing to, or are forced by necessity, to risk their own lives to provide the services the protected ones need – food, deliveries, cleaning, maintaining medical facilities, garbage pickup, and on and on. Only a very small percentage of the people in the world are in a position to go without a salary without great suffering and many deaths. Although mostly well-intended, overreactions to the dangers of Covid-19 have already caused many losses. We must find a wise way to balance the many goals, rather than falling back into simplistic thinking in either direction.
Unintended consequences
Lost jobs are only one of the many unintended consequences of our reactions to the pandemic. Using fear to keep people at home has had some value, but in many instances it has gone too far. Dr. Mihaljevic, chief executive and president of the Cleveland Clinic, and Dr. Farrugia, chief executive and president of the Mayo Clinic recently wrote that the fear generated by shelter-in-place orders and the closing down of normal life and work has made Americans who were seriously ill afraid to go to the doctor or to hospitals, which, in their view, will lead to many deaths, perhaps as many as Covid-19 itself. In the U.S. alone there has been an almost 50 percent drop in children being vaccinated for measles during the first quarter of 2020, compared with the same period in 2019. This has been true in many other countries as well, to the point that at least 25 countries had suspended mass measles immunization campaigns by late spring. This will inevitably mean a widespread resurgence – and measles is much more contagious than the SARS-CoV-2 virus, and very deadly.
All over the world, vaccine programs have come to a halt, or been dramatically curtailed. Now, diphtheria is appearing in Pakistan, Bangladesh and Nepal. Cholera is in South Sudan, Cameroon, Mozambique, Yemen and Bangladesh. A mutated strain of poliovirus has been reported in more than 30 countries. And measles is flaring around the globe, including in Bangladesh, Brazil, Cambodia, Central African Republic, Iraq, Kazakhstan, Nepal, Nigeria and Uzbekistan. Yet societies, including wealthy ones, are now organized around the assumption that these diseases are not much of a threat. Thus, as they spread in less-developed countries, they will also reach our shores in increasing numbers. The cost will be very high, an unintended consequence of the breakdown of immunization programs, caused by the spread of fear around Covid-19.
In another area entirely, restaurants, along with schools that provided food for millions of children, were closed, leading to the unintended consequence of farmers plowing under countless acres of ripe vegetable fields, dumping millions of gallons of milk and smashing millions of eggs, because the government had shut down their customers, and getting perishable food quickly into a new supply chain is not possible.
Still another is, by telling people to stay indoors, or forcing them to, and closing outdoor areas (when it is safer outdoors than inside) has spread the disease within many family groups and crowded housing situations. This in turn is now creating rebellion all over the world from people who have been pent-up too long. In general, telling, or forcing, people to stay at home has become a recipe for rebellion against the rules. Saying to hundreds of millions of people in the U.S. that, if they would stay home for a month or so, they would “flatten the curve” and beat this problem, was not a thought-through solution. This was never going to work, because this was never a short-term problem. In areas where there was a major outbreak, sheltering-in-place was valuable, but it was not a good idea for every area in the country.
Most people accepted the rules, however; most did try to stay at home for a while. But there had been little consideration by the rule-makers about what would happen when the disease was still very much present and the economy started collapsing, or when millions upon millions of people began to realize that the short-term solution wasn’t going to be enough. More and more people began to ask: What is the plan now? And there was none. And we are discovering that closing down is much easier than opening up. Since the virus is not going to disappear, how much do we open up, and when. Those who advocated strict shutdowns did not have a plan, and we are now suffering the unintended consequences.
The realization of the blindness of their elders has been especially acute for young people. If late teens and people in their 20’s are asked to stay inside and away from their friends, school, and all social activities for 3 weeks, even a month, they will mostly accept the restrictions – if it seems important for their loved ones. Some will do it to protect themselves, and some for the good of society. But when they begin to realize that the adults don’t really know what they are doing, that sheltering-in-place for a month or two is not going to stop the pandemic, they will break out of the rules. I think I would have too, at that age. This is now true, in fact, for increasing millions of people of all ages. The dam has broken, and many people no longer trust leaders who propose severe restrictions with no end in sight.
All this is one of the reasons for the protests and riots that have broken out around the country. Make no mistake, there are very real grievances that need to be addressed, and the brutal and totally wrongful death of George Floyd is inexcusable. But the explosion of people in the streets is also a consequence of people breaking out of what they increasingly see as an overreaction of restrictions on how they live. Young people especially cannot be caged in for long. Going hand in hand are the lost jobs, and lost job prospects, especially among young people. As more and more realize that their jobs are not coming back, and that new job opportunities are slim, the pressure mounts. As one protester said after looters smashed the windows of a Duane Reade drugstore in Lower Manhattan. “Unemployment is gasoline, and then abuse of power is the match.”
The point of the above is that we should have, and need now, to focus our efforts on those places and situations that are the real danger spots, and not impose broad rules that do little good, rules and restrictions that cause resentment, disrupt lives, destroy jobs, waste money, and cannot be sustained for the length of time this virus will be with us.
Finding Balance, Using Common Sense
In an earlier essay entitled “Mistakes,” I summarized many of the mistakes made in the United States, especially by the Trump administration, that led to the unfolding catastrophe of death and disease we are experiencing now. It is also important, however, to recognize the faulty reasoning that led to the overreactions. One is that, if you insist that people stay locked away before it is necessary or practical to maintain, they will break out with a vengeance – which we are seeing all over the country.
Human nature was not being taken into account by many of the people wanting to lock things down all over the country. Or they were deluding themselves about how long we would be dealing with this disease. It should have been clear to anyone paying serious attention and giving it any reasonable thought that this was going to be a long-term problem, and we desperately needed plans that could be put in place and sustained for 2 years. We failed miserably at this in the U.S., and the consequences will cost many lives. We should have had several gradated steps of action, and saved the most intense ones for when they were really needed – like in New York during their intense period. (And of course, we should have set up a testing and trace plan from the start.) But because many locales without much disease overreacted and tried to “lock down,” more and more people are rebelling – and I doubt the great majority of Americans will accept severe restrictions again any time soon, even if the disease worsens.
One of the reasons for this mistake was that we looked at what China did to stop their outbreak, and somewhat tried to copy it, without considering the great difference between China and the U.S. China is a police state, and they have both the ability and the existing organization to lock down a large area of the country and enforce it over time. And the population has been trained for centuries to comply with authority. What was anyone thinking when they tried to copy China’s tactics for this disease? It was never going to work here – and clearly hasn’t.
An example in the opposite direction that we did not copy is Sweden. They made mistakes: they did not put a large testing program in place, did not pay enough attention to their nursing homes, and did not deal as well as they should have with their immigrant labor population. But they devised a plan that took into account the nature of the majority of their own people, working with who the people were. And from the start they said it was a long-term plan. They have had higher rates of disease than some other countries around them (but about the same as we have had in the U.S.). The advantage they have is that as other countries try to open up, Sweden will be able to just keep doing what they have been doing, hopefully tweaking it a bit to make it better. As Europe reopens, it is likely that more people in Sweden will already have immunity than most other places. My guess would be that after 2 years, their disease rate will be as good or better than most other countries in Europe, their economy will have suffered much less, and their lives will be working much better with each other and within their communities than most any other place.
Even better models that we could have followed are Germany and the Netherlands. Both used testing and tracing extensively, prepared and supported their medical communities, and used limited restrictions to contain the spread of Covid-19. Crucially, they helped companies maintain people on their payrolls rather than allowing massive layoffs and firings. By and large, they did not “lock down” their countries. Germany was fairly strict, and Holland much less so, but neither used fear tactics to keep people inside for weeks and weeks. Especially the Netherlands. And today, while the U.S. has had 355 deaths per million people – with that number heading much higher – Germany has had only 106 deaths per million, with new cases and new deaths down dramatically. Because they were much less strict than Germany, the Netherlands has had 354 deaths per million, about the same as the U.S., but the number of cases and deaths there are falling significantly now, unlike the U.S. Crucially, there has been little rebellion against the rules. Although Holland’s short-term result is worse than Germany’s, the real result will be judged on what happens over the next 2 years. As things open up more in the Netherlands, people will be much more able to keep doing what they have been doing, and after 2 years they will likely have a disease rate as good or better than most other countries in Europe. And importantly, their economy will have suffered much less and their lives will have been less disastrously affected.
The importance of thinking clearly
I have read several articles recently speculating about how many lives were saved by “lockdowns.” But most are misleading and useless in trying to think about how to move forward. One, conducted by Imperial College London said wide-scale rigorous lockdowns “averted 3.1 million deaths in 11 European countries.” The assumptions underlying this “study” are that Covid-19 was like a tsunami that was hitting Europe and rolling over it all at once, that it was going to devastate every locale equally and simultaneously, and that once it had started there were only two options – a complete lockdown of Europe or 3.1m deaths in these 11 European countries. This is false on every count.
As Martin Heidegger said, it is very hard to see beyond one’s own “assumptive horizons,” and this is certainly true of the authors of the paper. Like so many similar “analyses” by people who believe their already-established point of view, they blithely assume things that are simply not true, such as that there were only two possibilities: a lockdown or doing nothing. However, between these options were hundreds of possible graded variations of action that could have been (actually were) applied in many different ways in different locales all over Europe. There was no lockdown of Europe. And there were not 3.1 million lives saved by this “fantasy” lockdown.
One big mistake in their argument is contrasting their “lockdown” against a second fantasy, a “do nothing” option. That did not exist either. Once the virus started spreading in Europe, people were going to take various actions to mitigate it – without a government “lockdown.’ In some countries, people would have done a lot on their own, in others, not as much. But the people in each locale would have taken various steps, and these actions would have reduced that potential “3.1 million deaths” by a lot. Without any lockdowns. How much? No one knows. Add in various government actions short of a lockdown, and, depending on the steps, the country, the specific locale within each country, perhaps as much as 98%. Or 75%. Without any lockdown. I don’t know what the numbers would have been, of course. No one does. It would have been 60% in one locale, 72% in another, 99% in another, and so on. But this certainly means that to say the lockdown “averted 3.1m deaths in 11 European countries” is just plain false. Sweden had no lockdown, Belgium had a fierce lockdown. Belgium has had twice as many deaths per capita as Sweden. So, using the logic of the article, the lockdown in Belgium cost many thousands of lives.
Re-enforcing the sense that this statement was written by people having little grasp of logic is that two paragraphs later in their paper they contradict their own argument, saying that the Japanese successfully beat the outbreak, “in a manner less disruptive than extreme measures of social distancing.” Thus, without realizing what they are saying in relation to their own previous point, they specifically say that a lockdown was not necessary at all, because the Japanese did not do it, and had a successful outcome. In fact, using the logic of their argument, the conclusion to be drawn would be that, since Europe has so far lost about 300 lives per million people to the pandemic, and Japan has lost only 3 lives per million people, the “lockdown” they imagine happened in Europe was the cause of 297 lives lost per million people.
That is not what I am saying, of course, but it is the conclusion that would come from using their logic and their facts. My point is that the example of Japan shows what is actually important and what works – which is wise testing, tracing, and a focus on educating people about the “three C’s”: limiting exposure to (1) closed spaces, (2) crowds and (3) close contacts. Those steps used in combination have worked everywhere they have been tried. Without the necessity of a lockdown.
As the world reopens, the crucial thing for each locale is to focus on the steps we should have taken in the U.S. from the start – extensive testing, tracing, isolating carriers, and a focus on educating people about the “three C’s.” Then, if the disease seems to be breaking out in a locale, a focused, time-limited “lockdown,” like that which was necessary in New York City for a time. But to “lock down” upstate New York, to tell people to stay off of the streets of small towns all over America – in places in which there were almost no cases of the disease – was pure foolishness. And very harmful in the long run – because it was the proverbial “crying wolf.” People will hide the first time, maybe the second, but they won’t keep responding to scare tactics. And that is what we are seeing all over the U.S. right now – perhaps as many as two hundred million people are saying to hell with all those restrictions. And we will, of course, pay a huge price for this rebellion by a resurgence of the disease.
Besides thinking of this disease as a short-term thing, another bad mistake was thinking of mitigation efforts in globalized terms in a country the size of the U.S. We needed a broad national framework, but most efforts should have been focused on specific locales within a broad plan. Local plans would have depended on population density, methods of transportation, patterns of interaction, and the amount of the disease present. For many of our efforts, we should have (should now) think about each SMSA as a specific locus of action, just like in a war. There is the overall war, with the overall goals, but actions vary in each specific theater of the war. That is how we should think about this problem. Again, as I wrote in my early essays, there should have been a coordinated overall strategy, but within it many local variations and different actions for each locale fitting into that overall strategy.
Within every plan of action the important questions always were, and still are: how many restrictions; how much social distancing; how much to give people guidance and then leave it up to them versus imposing mandates; how to fine-tune for different locations, etc. Within all the choices that different countries and regions have made, we won’t know what worked for at least another 18 months or more. What will happen in countries that locked down, as they reopen? What will happen this winter? Will the lockdowns end up making things worse in re-openings, or when winter comes? Will the fact that fewer people have immunity in the countries that locked down end up having a negative impact? And will the “lockdown” countries recover as much economically as those that were more relaxed? I don’t know – and no one else does. But I know that, of the many gradations between locking down and not locking down, what will end up saving lives and what will end up costing lives in the long run is completely unknown at this point. And I know that using numbers like “3.1m deaths in 11 European countries were averted” is harmful, for it distorts thinking about what we should do now.
Being safe
Another false conflict is that of safety. We do not live our lives just to be safe. Would everyone be safer if it was forbidden to ride in automobiles? If so, why don’t we insist everyone stop using automobiles? Why shouldn’t the government ban all automobiles – it would save close to 40,000 lives each year in the U.S. and prevent millions of mangled bodies. How can we possibly accept having automobiles, if safety is the primary issue?
And if safety were the only issue, no one would ever go skiing, climb a mountain, rock climb, or even play most sports. No one would become a policeman or policewoman, collect garbage, become a roofer or logger, or travel to most foreign countries. Or eat sushi. Further, during flu season every year we would all stay at home for months, or if we had to venture out, we would always wear masks everywhere we went. After all, flu kills many people every year.
The issue, of course, is that while safety is important, there are many other things that are important as well. Life can never be made completely safe. Although we humans have a natural longing to feel totally safe, that is not a possibility. So, we learn to balance competing desires. We have to balance safety with living life and accepting risk. And in this crisis, since this virus will be with us for years to come, we must think in terms of probabilities, and use common sense.
For instance, although some studies have shown that SARS-CoV-2 can live 2 days on metal, this is totally beside the point, because there is not one single study showing that anyone has ever been infected by the Covid-19 virus living on metal for that long. In fact, many of these studies are not finding active viruses that can infect, but simply genetic traces of the virus that are not capable of causing an infection. Further, just because a single virus might survive on a doorknob for a few hours tells us little of importance. What is important is whether a sufficient virus load can survive in a particular situation with a significant probability of causing infection. And from the information I can find, this is certainly not days on any surface I am encountering in the world. There is really no evidence I can find that anyone has been infected by touching any normal surface in the normal world after a virus landed there more than 24 hours earlier. This is important, because it means that time is an effective weapon in our arsenal.
Social distancing
One wise way to increase our safety is through social distancing. Not shaking hands, not hugging friends we meet in most social situations, and in general, keeping more distance when we interact with other people in the world. These are obvious ways we can protect ourselves and each other. At the same time, it is important that we not go too far and insist on things that increase fear, or feelings of isolation, loneliness, and depression. The World Health Organization has warned of a looming mental illness crisis, the result of “the isolation, the fear, the uncertainty, the economic turmoil,” brought on by the pandemic and our reactions to it. Another study by the Census Bureau suggested that a third of Americans were showing signs of clinical anxiety or depression at the end of April. In early May, half of those surveyed said they felt “down, depressed or hopeless,” double the number who responded that way in a 2014 national survey.
The crucial point to be made is that there is no evidence that many of the mandated restrictions causing these extreme reactions are very important, and they certainly cannot be maintained for years. Since this virus will likely be with us for that time, we have to find wise, common sense ways to restore social interactions while being as safe as possible.
I personally will avoid most crowded places and will encourage my friends to do so until this pandemic is under greater control. But should all places that might be crowded be closed or banned. If so, for how long? Who has the wisdom to draw the line between crowded and not crowded? Is a restaurant will tables separated crowded? Is a church crowded if people are being careful inside? Is a museum crowded if people can stay a few feet away from each other most of the time? To police such things is impossible. If a fierce outbreak occurs in a given location, then dramatic steps should be taken for period a time in that location. But governments cannot make minute decisions and micromanage all the details of our lives in a way that will make sense for the duration of this pandemic. What the government can do is provide clear guidance about what seems to be safe and not safe; require organizations that serve the public to make information available about the situation in their venues; educate people about risks; then let people make decisions about how safe they choose to be.
Personal hygiene
Another thing that is dramatically clear is that simply following a few personal hygiene practices is the best protection against becoming infected by the SARS-CoV-2 virus. Train yourself to clean your hands thoroughly any time you have been out in public – before you touch your face. Be mindful of the things you touch in the world or that you bring into your home that might have been touched by someone who is infected. Clean your hands thoroughly after touching any object that might pose a risk, and clean objects you bring into your home that might be carrying the virus. This is probably the best way to be safe in the time of Covid.
Will a vaccine save us?
Back in 1968, the Hong Kong flu was caused by a virus similar to other flu viruses, so an initial vaccine was developed in a few months (by August 1968). In spite of that, there was still widespread illness in the fall and winter of 1968. Even more troubling, although that vaccine was widely available before the start of the flu season in the fall of 1969, the second wave of flu during that time was even more deadly than the first wave in 1968.
Also troubling is the fact that the Hong Kong flu is still with us today (as the H3N2 strain of the influenza A virus). Several vaccines have been developed and used through the years, with some success, but these successful vaccines have not prevented a lot of people from being sickened and killed by it every year. (Vaccines have reduced the number of infections and deaths, but by no means eliminated them.)
The difficult lesson here is that we cannot count on a vaccine in the foreseeable future to remove the dangers we face from the SARS-CoV-2 virus. I believe we will develop a vaccine, but it will not be fully tested and widely available until the fall of 2021 at best. For comparison, more than 30 years after scientists isolated HIV (the virus that causes AIDS), we still have no vaccine for it. The dengue fever virus was identified in 1943, but the first vaccine was approved only last year. Two other coronaviruses caused lethal outbreaks in recent years, SARS and MERS, but we still have no vaccine for wide use for either (although research on those viruses is helping in the search for a Covid-19 vaccine). The point of this history is simply to show that we must make our way forward through this pandemic without placing our short-term faith in a vaccine, or thinking the problem will be solved by one any time soon.
Focusing wisely
Covid-19 has been most prevalent and virulent in certain situations:
Nursing homes and senior citizen centers
Prisons
Meat-packing plants
Medical environments treating those infected
Close social encountering (densely packed bars, concerts, sporting events, churches, political gatherings, etc.)
Mass transit systems
Migrant labor and other crowded housing and working situations
Large and extended families interacting with family members
As a country, and at the governmental level, our main efforts at mitigation should be focused on these places and situations, rather than creating broad fear and encouraging people to do things that have little impact.
For instance, there is growing evidence that this virus is not easily spread outdoors, unless you get close to someone who is infected and stay in their presence for a while, such as having a conversation in close proximity. Just passing someone on the street who is infected poses little danger, even without a mask.
There is also little evidence that being inside a store where you can maintain a reasonable distance from others most of the time poses much risk – if you clean your hands after leaving the store and don’t touch your face while you are inside.
It is also important to keep reminding ourselves that there is so much we do not know. For a while wearing gloves was recommended, but now it seems that for the average person in a normal day, gloves are more likely to cause infection than to prevent it. Another area that is puzzling is whether closing schools is valuable. Many schools were closed in many countries, but it is not clear how effective that has been. And it certainly cannot be maintained for two years. A number of experts are now concluding that closing schools was not an important step in many locales, and some countries that did not close their schools seem to have had few negative consequences. This is an area that is very unclear at this point, but if we think of this disease as being with us for years, we have to find ways to open our schools while minimizing the dangers.
Still another issue is whether to wear a mask, and if so – when, how, and made of what. Masks have become a flashpoint in this country’s culture war, partly because there is little scientific evidence about how much they help, what kinds of masks are really useful, and when it is important to wear them. So far there has been no way to distinguish the importance of masks from all the other measures being taken in various locations around the world, so the importance of mask use is speculative in most situations, except tightly controlled uses such as medical environments. Some places that have contained the virus believe masks were important, such as the densely-packed city of Hong Kong. When the virus first appeared there, most everyone started wearing a mask whenever they left home, and they believe that was an important factor in the successful containment of the pandemic. But several countries have not used masks very much, yet have had good outcomes during this pandemic.
Again, studies are all problematic, because there are always many different factors at play, but one interesting comparison involves Belgium and the Netherlands. The two countries share a long border, have many things in common, and there has always been lots of travel back and forth between the two – some people living in one country close to the border often do their regular shopping in the other. As the pandemic began during the early spring, Belgium imposed severe rules for closing businesses, limiting travel, stopping people from going outside, and requiring the use of masks, while the Netherlands adopted much less strict policies. Masks were not worn in many situations in the Netherlands, while being required in Belgium.
The results? As of late May, Belgium has had twice the number of cases of Covid-19 as the Netherlands, and Belgium has had 806 deaths per million people, while the Netherlands has had 342 deaths per million people. Jaap Van Dissel, head of the infectious diseases department at the public health institute RIVM in the Netherlands, and an advisor to the Dutch government, says widespread use of masks is not important. In fact, he is more concerned that using masks gives rise to a false sense of security and that people stop washing their hands and keeping their distance when masks are made compulsory. Tess Lauret, an expert in disease prevention at Amsterdam’s UMC teaching hospital said, “Home-made masks are also not a solution. The virus can get past them. You think you might be safer but you are not.” Other experts say that “the virus also enters the body via the eyes and through not washing your hands, and that removing a mask that has been worn all day is a hazardous operation in itself.” Other researchers have emphasized other problems with mask use by the general public: reusing masks without a thorough cleaning between each use is dangerous; taking a mask off and on during the day without a thorough cleaning is very problematic; masks are having a negative effect on the way people communicate and relate, and wearing a mask for an extended period of time has its own negative health effects.
I don’t personally know when and how masks should be used, but no one else does either. They have a role to play, but they should not become a purity test. How can we have come to such a place in this country in which wearing a face mask has become a symbol of the tribe you belong to? Today, many people have organized around whether or not to wear a mask, like gang members organize around wearing the symbol of their gang. On both sides, the evidence has been jettisoned in favor of picking one’s symbol of tribal membership. This is not wise. There is such a split in our country, and it is getting wider and wider, and masks have become a symbol of that division. I live in Sevier county, Tennessee. Gatlinburg, 10 miles from my home, is now totally packed with tourists, the shop-lined streets are crowded, the stores and restaurants are full – and almost no one is wearing a mask, inside buildings or outside.
If I drive toward Knoxville and stop at the plant store one mile from the Knox county line, perhaps one in ten customers is wearing a mask, and none of the people working there are wearing one. The closer I get to Knoxville, however, the more people are wearing masks (few in the Kroger inside the county line, more than half in the Kroger in the city proper). Yet both Sevier County ad Knox county have had few cases of Covid-19.
Again, I do not know exactly when a mask should be worn, but three things I do know:
1) Masks have a role to play, but widespread use is not crucial in defeating this disease, as demonstrated by the successful countries that did not use masks very much. To emphasize once again, the crucial things are testing, contact tracing, wise isolation of probable carriers, personal hygiene, wise practices in keeping social distance, reducing crowed situations, and focusing on dealing with nursing homes, prisons, meat-packing plants, medical environments, mass transit systems, and the crowded working and living arrangements some groups of people face.
2) It is too late to have widespread voluntary compliance for mask-wearing in the United States. The battle lines are already too fiercely drawn. In this environment, mandating masks in situations where they have limited value will only cause rebellion. In light of this, we need to use common sense in thinking about masks. If, as I suspect, the odds that I will contract Covid-19 while walking down a not-very-busy street in Knoxville without a mask are infinitesimally small, then wearing a mask that is 90% effective against the virus is a silly thing to do. This highlights the problem with the studies that breathlessly show that a mask is 90% effective. The crucial issue is not how effective a mask is by itself. That number only has meaning in relation to the risk in a given situation. Yet I have not been able to find one study that does this, which means I have seen no studies that provide meaningful information about the value of a mask in most of the real-world situations I encounter in my normal life. As a comparison, there are about 230 million cases of malaria in the world each year, and over 400,000 die from it each year. When I go to areas of the world that have a lot of cases of malaria, I take precautions. This is how we need to think about masks and Covid-19 – in situations that have a high risk of transmission, I will wear a mask.
What if the goal is to protect others? Then my practices listed above, plus not interacting with many people (hardly anyone I know even knows anyone with an official case of Covid-19), seems like enough. In this circumstance, should someone who “believes” in masks tell me I must wear a mask when walking down an empty street or in a park or in a non-crowded store? This seems like an imposition serving no purpose, and even if I am willing to comply, an increasing number of Americans will not.
3) What this means is that, in a country as large and diverse as the United States, where mask wars are already raging, masks will not be a broad answer to our problem. They can and should be used selectively and precisely – such as in a city in which a significant outbreak is occurring, and in situations in which people who don’t usually interact with each other need to be close contact – health care providers, hairdressers, beauticians, physical therapists, etc. And to protect others, anyone who thinks they might possibly be infected, whether they have symptoms or not, should stay home until they can be tested – but if that person feels compelled to go out in public, that person should wear a mask. More generally, if you are going to be in close contact with people outside your immediate circle, wearing a mask is a valuable tool to protect them, and to a lesser degree, yourself.
Testing – the top priority
Let me end with one of my first points: Wise, well-thought-out testing, tracing of contacts, and isolating those who might be spreading the disease has been the most important mitigating action all over the world. The countries that have implemented testing early, with an effective strategy for its use and follow-up, have been able to contain the disease.
Wise testing, however, does not mean hit-and-miss testing. It means finding ways to test those most likely to be infected, getting the results rapidly, and finding the contacts of those who test positive quickly and isolating those people. Several countries have done this, in somewhat different ways. How they have had success can be copied. One valuable example is Japan, where Covid-19 was controlled without stringent social distancing measures in most places, and even without trying to test a large percentage of the population. Instead, Japan relied on largely voluntary measures encouraging people to stay at home and advice to avoid overcrowding in public venues, while adopting an “anti-superspreading strategy.” In essence, the goal was to find and isolate those few individuals who seem to have been the main spreaders of the disease. (Some estimates are that a few “super-spreaders” have been responsible for as much as 80% of the cases in the world.) Using these methods, Japan has had great success with actions far less disruptive, socially and economically, than the lockdowns much of the world has endured over the past few months,
A few other countries, like Japan, have had remarkable success in avoiding the ravages of this pandemic. Some of these countries are small and isolated, like Iceland and New Zealand, so it is be hard to apply their tactics to a country as large and diverse as the United States. But Japan, Germany, Sweden, Switzerland, the Netherlands, and several other countries have used strategies from which we can learn much. If we could only stop making this disease a political battleground and turn our considerable wealth and knowledge toward a plan most of us could support, if only our leaders would help us do this, it would save many lives and much national treasure.
Today, however, the disease is so pervasive in the U.S. that we need to encourage every person who has any symptom whatsoever of Covid-19 infection to get a test immediately. We need to make sure everyone in the country knows a test will cost them nothing, and that if they test positive, quarantine will not be a financial burden in any way – that they will be taken care of if they need help. Further, anyone who has had contact with a person who tested positive must be provided with help if they need to isolate for a time. Investing in this testing program would save many lives, and avoid much greater costs from the spread of the disease over the next 2 years (many trillions of dollars have already been spent in the US., much of it to little effect.). If only that money had been invested sooner in a thought-out testing program. But still, at this late date, the best way to staunch the bleeding of resources is to make sure that people who might possibly be spreading the disease are motivated to be tested and then to cooperate immediately and fully.
State and local governments will play an important role in this, but the best use of the trillions of dollars of federal funds being spent today would be to make sure we have enough of the best and fastest tests available, that they are free, that people are motivated to use them, and that a wise plan for testing and tracing is in place nationwide. This is the most likely way we will be able to mitigate this pandemic short of a vaccine.
In the meantime, each of us must find the best balance between the extremes, learning to live our lives fully without an abundance of fear in this Time of Covid.
May you be safe,
May you be well,
May you live a full and meaningful life
In this time of Covid.
David
