We need better data, and we need to test specific standardised communities to assess the true nature of the medical risk we face. Only then we can move beyond empty models to hard-headed decisions about just what level of geopolitical defenestration and societal impoverishment we are prepared to accept in order to maximise our efforts to stem this pandemic. We need to change course, and we need to do it quickly.
By Matthew Parish*
The first observation to note about the recent global lockdown in response to the COVID-19 (Coronavirus) pandemic is that forcing people into isolation will not substantially reduce the rate of eventual infection of the world’s population. The medical evidence to date suggests that the virus is so infectious and yet slow-burning that eventually everybody will catch it. The infection rate will be 100%, less those persons (if any) who for whatever reason have some immunity to it. The origins of any such immunities, if they exist, are not yet known.
Governments instructing people not to socialise is not going to reduce the infection rate naturally below 100%. That is because everyone is breaching these instructions at least to some degree. Contemporary mankind is incapable of being unsociable indefinitely. Given the longevity of the infectious virus (up to three days on a surface as inhospitable as plastic), the actions involved just in buying food (nobody lives on isolated self-sustaining farms anymore) necessitate multiple interactions in which transmission of the virus is virtually inevitable. The same is true of actions involved in caring for the sick. So we are all going to contract this virus.
The good news however is that this virus is not very dangerous. The vast majority of those who contract it will recover fully, quickly. A small minority will die; but they may have died anyway, of some other virus or bacterium or other natural cause. The problem is that we do not yet know how many additional people may die or be at risk of dying, beyond those who would die anyway as a result of contracting the virus. What we do know is that if people show serious symptoms as a result of contracting the virus, their odds of survival increase substantially if they are hospitalised adequately, and emergency equipment, such as lung ventilators, is made available to them.
Therefore everyone is now constructing hospital beds. The proper goal of the lockdown is to slow the spread of the virus while we have time to build hospitals and equip them appropriately. It is not to decrease infection rates. Indeed it barely a takes a leap of the imagination to realise that lockdown may ultimately increase infection rates, by prolonging the period of total population exposure to the virus; therefore because the virus will kill the people it kills less quickly, it will not kill itself off as quickly. Contrast Ebolavirus, whose proverbial fatal flaw has traditionally been to kill its victims more quickly than it can spread to new victims. Ebolavirus has recently been evolving its way out of these limitations. The saving grace of contemporary viruses is that they are not so deadly as to limit their own transmission.
Because there is currently no widely available test for Coronavirus, and its symptoms are not significantly distinguishable in many cases (particularly milder forms of the infection) from the symptoms of various other viruses, we have very few reliable figures. We have no useful figures for infection rates. It is therefore unjustified to say that Italy has a higher infection rate than some other country, unless we are applying identical cross-sectional population testing which we are not because the testing methods permitting this do not yet exist.
For the same reason we cannot say that Coronavirus is more fatal in Italy once contracted, because we do not know how many people in Italy have contracted Coronavirus and hence we cannot say whether that is a higher proportion of the population of Italy than any other proportion of any other country’s population. Moreover the ideas that Italy’s infection rate is the product of either (a) some statistical fluke in transmission; or (b) some unique cultural or political environment encouraging the virus’s propagation, both sound inherently unlikely. When everything comes out in the wash, the likely infection rate in Italy will likely be the same as everywhere else – near enough 100% – and the likely death rate will bear a relationship to the number of equipped hospital beds with ventilators.
We do not even know how many people have so far died by reason of Coronavirus, because we cannot isolate a proportion of those who die with Coronavirus who would have died anyway. Rather the only reliable data we have is what proportion of people who come into hospital testing positive for Coronavirus die; and we can subdivide that data into proportions of people dying who are (a) sent home again without treatment, versus (b) kept in hospital with a ventilator. The latter proportion being lower than the former, we are building hospitals and buying ventilators and trying to slow down transmission until we have enough beds and ventilators to cater for our worst case statistical modelling scenarios about the proportion of people likely to die (a figure we cannot know until we have a reliable test; we are only working on unjustified assumptions for now).
To illustrate the logic of this, imagine a community of 1000 people ravaged by Coronavirus (all the following figures are fictionalised, merely for the sake of preserving mathematical simplicity). Let us assume that the community infection rate will be 100%. Let us assume that x% (I will call it 20% for the purposes of this example) of persons infected (i.e. 200 people) will fall into the severe category and will seek medical assistance. Of those, 50% (100 people) will die unless treated with H+V (hospital bed plus ventilator); in which case 25% will die (50 people). To minimise the deaths, you need 200 H+V’s, so you slow the progress of the disease by ordering your community members to self-isolate until you have built them. Even though your community will not self-isolate properly (this is virtually impossible), you buy yourself time to build the 200 H+V’s.
However a society does not actually need that many H+V’s; the more effectively your population self-isolates, the slower the spread of the virus and therefore H+V’s can be used over. There will be a correlation between infection spread rate and the number of H+V’s you need; let us say that for a given infection rate you will only need y% of 200 H+V’s because patients using H+V’s will recover (or die) in time for the next wave of infected patients to seek medical attention. Tough self-isolation reduces the number of H+V’s you need to minimise deaths and therefore saves the government money as well as gives you time to build the H+V’s; hence the system will not be overwhelmed: something that would cause unnecessary deaths at the early stages. This is the logic of the Coronavirus lockdown.
The figures of 50% and 25% in the foregoing calculation can be calculated and known based upon the methods currently available to us. You count the number of people who seek medical attention and have Coronavirus. You count the number you treat with H+V and the number you do not treat. You count how many die and how many recover. These figures are available to western health services. The figure of a 100% eventual infection rate is not available to us, but it a good working assumption given what we know about the ease of transmission. All the other figures we do not know, and we cannot know until there is widespread testing.
Therefore we do not now actually know the optimal number of H+V’s a society needs to minimise deaths, and we will not do so until we have a comprehensive system of testing. With testing, we will be able to tell how quickly the virus spreads under different circumstances. We can then undertake experiments such as locking down different parts of a country to different degrees, and compare the time scale for the virus to spread. We can also tell what proportion of persons infected have symptoms serious enough to seek medical attention. This way, we can calculate x and y in the above examples for our society, and we can assess the optimum number of H+V’s we need to minimise deaths. But until we have widespread testing, we are just guessing.
The media is full of images across the world of people building hospitals and buying ventilators. We do not yet know whether we are building and buying the right numbers. It is entirely possible either that we are not building enough, and ill people will be sent home when they could benefit from treatment; or that we are building far too many, and images of conference centres full of hospital beds placed there by soldiers will become future relics of humankind’s folly in the quest to harness an unknown enemy.
Human life has a value. The UK National Institute for Clinical Excellence, a pharmaceutical regulator, assesses it at approximately GBP30,000 per year, and will not license medications costing more than that in the continuation of life. Building / purchasing H+V’s also has a price, but it is negligible when we consider the current global losses being suffered. In terms of political economy, constructing hospital facilities also has a benefit to hospital managers / bureaucracies that will run them, as they seize budget lines and political influence. When the scientists and doctors responsible for the speculative statistical modelling, that generates assertions about how many H+V’s a society needs, fall under the managerial responsibility of those who obtain a political economy net benefit from constructing them (health ministers and the like), there is a palpable potential for conflicts of interests.
It would not therefore be surprising were it subsequently to turn out that we have built far too many H+V’s. The costs of building them must be weighed against the other uses to which national healthcare budgets might be put, placing a value upon a human life to enable such comparisons. This ought also to serve as a restraint upon the quantum of healthcare efforts spent creating hospital bed and ventilator capacity. At some point, we are wasting money better spent curing people who are seriously ill in other ways.
There is already anecdotal evidence emerging of domestic medical care systems’ neglect of other patients, and in some cases a massage of statistics. In some parts of Italy, any death in a hospital that treats Coronavirus patients (that is to say, virtually all of them) is treated as a death by reason of Coronavirus. This escalates the sense that Coronavirus is an overriding medical priority and inflates the already entirely artificial death rates cited in the media. We cannot even begin to calculate a death rate until we have an infection rate; we cannot assess that until we have uniform testing.
The far greater costs than those of building H+V’s are the economic, social and psychiatric costs of lockdown. Again here there is insufficient information to engage in even an imprecise science of lockdown. What are the optimal levels of lockdown? Sweden (light) and Italy (tough) stand as two opposing poles in the debate. Sweden has far lower Coronavirus statistics than Italy, but that goes to illustrate the dangers of casual correlations (should we all therefore follow the Swedish model?) and the incommensurability of different countries in the absence of standardised testing procedures.
The higher the level of lockdown imposed, the greater the economic, social and psychiatric costs to society. The principal benefit we have identified from a higher level of lockdown is the greater ability to construct H+V’s, that may potentially never be needed, in lower numbers and/or at a more leisurely pace and under less media-political pressure of newsreels of patients waiting in lines outside hospitals. One might be of the view that the former set of costs to society are inevitably going to be much greater than the latter. At the very least, we ought to be satisfied quickly with the number of H+V’s constructed and ease the lockdown so that its worst excesses in terms of colossal damage to society can be alleviated.
If values must be placed upon the healthcare system changes the Coronavirus pandemic has engendered, then likewise efforts must be made to evaluate the long-term costs of lockdown using a comparable metric. It is imperative that we make efforts to measure the world’s economic, social and psychological losses. A model that takes account of the fact that the societal damage done may extend indefinitely far into the future is imperative. Yet we have not even begun to think about how we might do this. Therefore we cannot currently weigh the harm we are aiming to alleviate, against the damage we are inflicting against ourselves. Moreover nobody has yet even thought about assessing the potential geopolitical consequences of different nations undertaking these sorts of balancing exercises in different ways. Each country may come out of this global crisis at a different geopolitical level from that it began at. The consequences of Coronavirus may be profound.
Instead of now discussing a relaxation of the lockdown given the improvements underway in our healthcare facilities, we are hearing narratives that we need even more of it. I do not know what possible logic can underly this, save for the logic of panic or self-beggary. China however is no doubt most content with the situation. Crude oil prices are now below $30 by reason of depressed global demand. That can only help swing the global oil markets to a demand-side model, cementing China as the world’s principal economic superpower by virtue of its consumptive capacity and correlative power to drive global markets. Demand-side commodities markets will take economic power away from Wall Street and direct it towards Shanghai. This may be a foretaste of the geopolitical political changes to follow. In the midst of this sweeping change in commodities pricing, oil pricing and supply disputes between Sunni and Shia, Saudi Arabia and Russia look like bald men arguing over a comb. The United States’ fracking industry will likewise be left awry.
At the end of the Coronavirus crisis, depressions in demand for consumer and other goods will surely become semi-permanent. That is because we are all going to have less money. We are all soon to learn that it does not much help anyone if the government compensates you for not working; it uses the money and resources of society as a whole to do this, and therefore we will all become impoverished in consequence. This may spell the demise of the economics of scarcity, as the value of money is no longer needed to regulate demand because supply outstrips the demand that has been permanently depressed. It is hard to imagine what a post-capitalist society may look like that has been transformed in this way. Do we want to take the risk, and is it too late to reverse course?
There is madness afoot amidst these mists. In these remarkable times, it takes clear thinking to understand the medium-term consequences of the social policy decisions we are making. In any other era, the election to self-castrate the private sector in favour of government bail-outs (which may result in partial nationalisation) and to inflate a healthcare sector outside market parameters would be viewed as ravings from the asylum. We need better data, and we need to test specific standardised communities to assess the true nature of the medical risk we face. Only then we can move beyond empty models to hard-headed decisions about just what level of geopolitical defenestration and societal impoverishment we are prepared to accept in order to maximise our efforts to stem this pandemic. We need to change course, and we need to do it quickly.
*Matthew Parish is an international lawyer based in Geneva, Switzerland and an Honorary Professor at the University of Leicester in the United Kingdom. He has been elected as a Young Global Leader of the World Economic Forum and named as one of the three hundred most influential people in Switzerland. He writes this article while self-isolating, suffering from the symptoms of COVID-19. www.matthewparish.com