Difficult times

How bad will it get? Two weeks ago I suggested to my wife that it might be a good idea for us to pick up a few extra non-perishables to keep on hand, just in case, because we wouldn’t want to get stuck with an empty pantry just as the rest of the world cleaned out the stores in a fit of panic buying. She laughed at me and I laughed at myself, and we joked about what further emergency preparations might be necessary. Was it finally time to purchase the year’s supply of food Costco offers for $6,000? (They appear to have sold out.) Foolishly, I failed to anticipate that toilet paper would be the thing everyone madly scrambled to stockpile, so while we’re in good shape on canned goods we might find ourselves rationing squares of toilet roll.

How bad will it get? I don’t know. But I’m more worried today than I was two weeks ago. I fear that America is setting itself up for—I don’t want to say disaster, but—a scenario far worse and more dangerous than ought to be the case.

The World Health Organization’s report on China’s management of the initial outbreak makes for interesting reading. The initial reaction was slower than it might have been, or than one might have expected given the country’s history with SARS. Medical professionals in Wuhan appear to have recognized the danger quite early on, but it took some time for the government to really mobilize against the new virus. The first cases appeared from early to mid-December, and doctors developed concerns about person-to-person transmission by the last week of December. Wuhan was not locked down for almost another month, however. We can speculate about the role of China’s political system in causing this delay. It may well have been the case that local officials were reluctant to share bad news with those at the top, or that those at the top were reluctant to hear it. But perhaps we ought to reserve judgment. 

Once the government responded, it did so extremely aggressively. Containment efforts within the province of Hubei have been draconian. Tracing of contacts seems to have been extremely robust. The WHO notes: “[I]n Wuhan more than 1800 teams of epidemiologists, with a minimum of 5 people/team, are tracing tens of thousands of contacts a day. Contact follow up is painstaking, with a high percentage of identified close contacts completing medical observation.” The effect of this work, in combination with mass screening across the country and fast and aggressive containment of any clusters found outside Hubei, has been to effectively halt the progress of the epidemic in China. The initial delay was costly. Based on the numbers we have now, there have been more than 80,000 identified cases in China and over 3,000 deaths. But it could have been a lot worse. China hasn’t beaten the virus, it’s important to note. The disease is in the wild now, and the only way China can protect itself against new infections is by closing itself off from the world in a manner that would be economically disastrous and socially unsustainable. But its efforts were not in vain. China bought itself and the world some very valuable time. 

The experience in Wuhan gives us some sense of what uncontrolled spread could potentially look like. What you get is a lot of cases in a very short amount of time. The rush of cases overwhelms the capacity of public health systems: hospitals become overcrowded, you run short of supplies and personnel, medical professionals get sick and die, and you wind up with a much higher fatality rate for the virus than would otherwise be the case (and, most likely, higher mortality rates for other illnesses as well). Spreading out infections over time makes them less deadly. While it’s worth treating numbers from China with some skepticism, the WHO reports a case fatality rate within Wuhan of 5.8% versus a rate elsewhere in China of just 0.7%. That’s a big difference. Beyond that, China’s interventions gave the rest of the world time to prepare: to make ready to test vast numbers of people, to screen vast numbers of people for symptoms, to isolate vast numbers of people, to equip vast numbers of health professionals with the things they need to treat patients safely and effectively, and so on, you get the idea. Finally, slowing the pace of the outbreak potentially reduces the number of people infected by the disease before effective vaccines or treatments are developed. 

It increasingly appears that America utterly squandered this opportunity to get ahead of the pandemic. It also looks increasingly likely that the US could face a more serious outbreak than China has so far experienced.

In my last dispatch, I noted the need to reckon with lag in thinking about the state of the outbreak. People who are confirmed to have the disease were likely exposed to it a week or two or three ago. So if you’re seeing tens of cases in several different states, then it’s a good bet that in a week or two you will be seeing hundreds or thousands of cases, and you will be seeing them everywhere. In America, however, the true extent of the outbreak is especially difficult to discern because of the woefully inadequate extent of diagnostic testing. This bracing piece from The Atlantic gives a sense of the mess. Tl;dr: we are far, far behind other countries in diagnosing and tracking the virus. 

One way this shows up is in the relatively high number of deaths in America as a ratio of confirmed cases. As of this moment, there have been 19 confirmed deaths from covid-19 in the US. Assuming a fatality rate of between 1% and 2%, that means there are actually somewhere between 1,000 and 2,000 people with the virus in America, rather than the 426 cases which have been officially confirmed. For context, as of the fourth week of January, when China locked down Wuhan, the government had officially reported roughly 600 total cases and 17 confirmed deaths.

Or rather, there were between 1,000 and 2,000 cases one to three weeks ago. The coronavirus is not a fast killer, and so new deaths represent infections that began quite some time ago. In the weeks since, the numbers have grown, out of sight. And cases have spread geographically. Once it was clear that there was community spread in Italy, it was a safe bet that the whole of Europe would soon experience large numbers of infections. Once there was community spread in any part of America, it became quite likely that all of the country would soon be in trouble. 

It’s hard to wrap one’s mind around the true extent of the problem, though. Even in the places hardest hit by the virus, hospitals cannot get enough testing equipment. People are showing up to doctors’ offices with symptoms, being seen and sent away without tests or diagnoses. The Trump administration has fought even basic steps to try to limit the damage done by the epidemic. Health officials wanted the White House to warn vulnerable people not to fly, but it initially refused to do so, for example. (The administration did ban travellers from China from entering the US, a step health officials argued against, and which did not prevent the virus from spreading to America.) At this point in its outbreak, South Korea was conducting mass testing. We are not. You can board a flight anywhere in the US, even the places with the largest numbers of coronavirus cases, and travel anywhere else in the country without anyone asking whether you’ve had a fever or feel ill or have been to a virus hotspot. The situation on the ground in the US is simple: completely uncontained spread, with only minimal efforts to track the true extent of the outbreak.

America also has vulnerabilities that other countries do not. We have a relatively low number of hospital beds and doctors per person, in comparison with other rich economies. Millions of Americans have no or threadbare health insurance. Employers in America are not required to offer paid sick leave. If your food-service worker wants to earn the money he needs to pay for a visit to the doctor to check out his nagging cough, he has to work his shift.

To cut to the chase: while nothing is certain, the likelihood that we will experience large-scale outbreaks, sufficient to overwhelm local public-health systems in many parts of the country simultaneously, is high and rising. I could be wrong; I hope I’m wrong. But it is increasingly hard to avoid the evidence pointing in this direction. Two things should be clear. First, it did not have to be this way. And second, that it has gone this way will have serious consequences. It’s just an illustrative example, but in a group of 1m infected patients, the difference between the death rate in Wuhan and that elsewhere in China is about 50,000 people.

The knock-on effects will be different too. The Italian government has announced a month long, total lockdown of Northern Italy, the heart of the Italian economy, home to 16m people. That will hurt, a lot. You start to think about Italy’s economic vulnerabilities, its divisive and chaotic politics, and you get to imagining how consequential a thing this lockdown is. Other parts of Europe will very likely have to follow a similar course of action. But with luck and care, some parts of the continent may manage to avoid doing so, and shutdowns might also be staggered in time, softening the economic blow. America, after weeks of uncontrolled spread, faces the possibility that its government might eventually have to choose between locking down much of the country, all at once, or letting the virus run free. The human and economic toll, in either case, is frightening to contemplate.

That is not where the matter will end, though. It doesn’t seem reasonable to argue that America is about to face a month or three of an acute public-health crisis and massive economic losses and will then go back to normal with things much as they were before. Things will break. Companies will go bust, people will get laid off, borrowers will default, and financial stability could be threatened to the point that large-scale government interventions are necessary. I don’t want to speculate about what other social disruptions could occur. But the demands placed on the government will be significant and the stakes will be high. 

Fighting crises is hard. Between 2007 and 2009, the White House was filled with people with a deep knowledge of the financial system and the economy, who recognized the severity of the situation they faced and who cared deeply about limiting the damage done by the crisis. But fighting crises is *hard*, and so they made mistakes, and those mistakes had consequences. The costs of the global financial crisis and its aftermath were not nearly as high as they might have been, but they were substantially higher than they needed to be (and were distributed in a way that was neither just or efficient). 

Let’s be blunt. The Trump administration has not taken this seriously enough. It has never been staffed with the competence and expertise found in most White Houses, and what competence and expertise there was has been driven out by now. Those who remain and have good instincts and good information cannot get their boss to pay attention. He would rather people die unnecessarily than face a bad headline; that sounds like a terrible slur, but it’s the trade-off the president said he was prepared to accept in comments on Friday. The president cannot bring himself to recognize the difference between the coronavirus and seasonal flu, or to acknowledge that the former is potentially much deadlier, or to share basic and truthful information about the virus. His actions have already created a situation in which more Americans will die than needed to. In the months that come he will be faced with critical decisions—the sorts of life-or-death choices of historical significance that presidents often face—and I’m afraid that we can have very little confidence that he will make them in ways that reduce the danger facing America and the world. These situations happen, which is why you cannot afford to put a man with the character and abilities of Trump in the White House, and why you cannot afford not to remove him when he has provided ample evidence of his unfitness. But here we are. The die is cast.

All is not lost, of course. America does have many competent leaders and public-health officials across its state and local governments. It is filled with medical professionals who are going to work very hard and make significant personal sacrifices to help the country get through the epidemic. Americans can be generous and unselfish. With luck, communities will look out for each other and we will catch some breaks with the course of the virus and eventually the worst of it will be in the rearview mirror. 

But the time has come to recognize how trying the next few months will be. Americans need to demand maximum accountability and transparency from the White House. State and local governments cannot count on getting appropriate guidance and support from the federal government. They need to cooperate with each other and take the lead in managing the crisis. And we all need to do our best to keep the situation manageable: to take appropriate precautions, and heed the advice of public-health professionals, and be savvy consumers of news, and look out for friends and family and neighbors. It will get better. It’s just going to have to get worse first.