It has been about a month since the world (or at least since my world) was turned upside down by COVID-19. I know I am getting tired of the isolation. More and more I am hearing rumblings from a variety of circles that it is time to end the stay-in-place orders and get America back to work. I certainly sympathize with the desire for a return to normalcy. I am moving from my home of 4 years in less than a month. This was supposed to be a time to be with the friends we have made here and say our goodbyes. It was supposed to be a time to be with our extended family before we move out of state. Instead, we get to sit at home in isolation. It is frustrating!
I also know that there are lots of people who have been affected far more than I have. Millions of people have lost their jobs and many are struggling to make ends meet. So, I completely understand how people would start to wonder, when is this going to end? Can’t we just get life back to normal?
Unfortunately, after reviewing the scientific evidence and the data on the outbreak, I have concluded that the answer is “NOT YET!” We cannot end the social distancing/lockdowns/stay-in-place orders until we are able to (a) determine how many people are actually immune to COVID-19 and (b) develop the capability to quickly identify and isolate cases of COVID-19 and people that have been exposed. Ending these orders prematurely will lead to the same spike in cases, hospitalizations, and deaths that we have been trying to avoid. Now, we can certainly debate whether every component of these orders is necessary, but regardless of whether I like or support the politicians who ordered them (I don’t), I support these orders and believe that it is in our best interest that they remain in place for the time being.
I recently read a blog post by a doctor that voiced some concerns about the “lockdowns”. I won’t link to it, but you can google it (search for eight-reasons-to-end-the-lockdowns-as-soon-as-possible on medium). I found this post very troubling and thought I would offer a rebuttal. Let me preface this by saying that I think that a conversation with the author would probably reveal a more nuanced position than the one he articulates here. I also think there are far more misguided and disingenuous opinion pieces proliferating online right now. However, I do think this one does exemplify the common arguments, and I find these arguments uncompelling at best and potentially dangerous. My hope is that this post will illustrate why these arguments should not be used to argue for an end to social distancing without having vital testing measures in place.
In the post, the author brings up 8 “reasons to end the lockdowns”. I will address these claims one by one:
Claim 1: We have already flattened the curve.
The author supports this claim with a graph (which appears to be from https://covid19.healthdata.org/) which shows a peak followed by a decline in the number of deaths. The problem is that the flat part of the curve is all in the future. The exponential growth displayed during the early stages of the epidemic has slowed in recent days and is closer to linear (which is great news), but it is far from clear that it has plateaued much less that it has decreased. All of the decreases shown in this plot are in the future projection. However, this model is based on the assumption of continued social distancing until at least the end of May (http://www.healthdata.org/covid/faqs). If the social distancing measures are lifted before we have widespread testing in place (so that we can effectively identify and quarantine the people that are infected) or herd immunity (through vaccination), then the number of interactions between susceptible and infected people will increase again and the rapid growth in the number of deaths that we saw earlier will resume (as any number of epidemiological models have predicted). This claim is inaccurate and naïve at best.
Claim 2: Economic collapse and unemployment are destroying families.
This is absolutely true and is a serious concern. However, it is also true that serious illness and death is destroying families. We should be concerned about both! Downplaying one at the expense of the other is not the solution. It is important to consider. Would ending lockdowns and stay in place orders allow employment to resume as usual? How many lives will be lost if those lockdowns are lifted? It is extremely troubling and easy to see the economic effects of the stay in place orders (just head to the grocery store), but that does not mean we should ignore the less visible (if you are at home) effects of the spread of the virus. We need to weigh the costs of both keeping and ending the lockdowns in order to make an informed decision.
Claim 3: We have not saturated the health care system
As the spread of COVID-19 has slowed (due to social distancing?), it has bought hospitals precious time to prepare for a surge. In some places like Detroit and New York that extra capacity has been essential. In other places, the surge has not hit yet and may never hit if we can continue to keep the virus at bay. It is true that there have been layoffs at hospitals (10% of the staff at the hospital in my small town) and that is a tragedy. It is fair to question whether canceling elective procedures was the right move and whether that needs to continue. However, saying that we have not saturated the health care system yet is not the same thing as saying that we WILL not. Using the same models that the author cited earlier (https://covid19.healthdata.org/united-states-of-america), we see that the model does predict that there will be shortages in beds, ICU beds and ventilators and that assumes that social distancing continues. If it is lifted too soon, then the shortages we experience will likely exceed those projected shortages.
Claim 4: Suicide may kill almost as many people as COVID-19 this year.
Suicide is a terrible thing and it seems entirely plausible that we will see a rise in suicides this year. However, whether suicide will kill as many people as COVID-19 is completely irrelevant to the decision of when to lift the lockdown. The question is how many ADDITIONAL suicides will we see as a result of leaving the lockdown in place. That should certainly be taken into account when weighing the costs and benefits of continued lockdowns, but the author does not really address that issue. He simply says that it might lead to more suicides. That is about as informative as saying “15 minutes could save you 15% or more on car insurance”. It is technically true but it is qualified to the point where it tells you nothing (you could save more…or not).
Claim 5: The mortality was likely overestimated.
This is true and the point has been made numerous times by experts for months. This is not news and it was well known to the very people who recommended social distancing in the first place. We are not social distancing because the mortality rate is 3-4%; we are social distancing because the mortality rate AND hospitalization rate are much higher than flu AND very few people have immunity to this virus unlike the seasonal flu. Social distancing has been deemed the best way to save lives at this point with the full knowledge that the mortality rate is likely below 3%. Even with the lower mortality rate, more people in the US have died from COVID-19 in 6 weeks than died during the entire H1N1 outbreak in 2009. So even with the case fatality rate being lower than the 4% we are seeing right now (https://coronavirus.jhu.edu/us-map), this is still a significantly more dangerous virus than the flu. You can find a more detailed discussion of the death rates and a comparison to other causes of death here: https://www.thenewatlantis.com/…/not-like-the-flu-not-like-….
Claim 6: Children are at almost no risk from this disease
This is true but also misleading. It has been well-established that children are at almost no risk from DYING from this disease. What is not clear is whether the extent to which they are at risk of SPREADING the disease. It is well-known that asymptomatic transmission is possible, so children could spread the disease to their teachers, parents and grandparents without ever getting sick themselves. The fact that most of the cases involving children have been so mild means that when they are infected, they are less likely to get tested (and therefore their infections will tend to be omitted from official statistics). Therefore our estimates for the prevalence of infections among children are even more uncertain than the estimates for adults. That is why testing is so important! Once antibody testing is widespread, we can get a better understanding of the risks associated with resuming school in the fall.
And as a side point, having kids home from school does not mean their education has to stop. There are many teachers who are putting together activities for kids to do at home and many parents who are working hard to help their kids continue learning from home. Let’s not downplay their efforts!
Claim 7: PPE was limited but is now becoming more available
Hopefully this is the case.
Claim 8: Authorities should show clear evidence regarding the benefits of indefinite lockdown.
There are so many problems with this section it is hard to know where to start. First of all, the indefinite part of the lockdown is simply not factual. Individual states have instituted temporary executive orders with fixed termination dates. As those dates approach they reevaluate the evidence and then determine whether to extend them. In Michigan the original order was supposed to last until April 13. It was later extended until the end of April. This is not indefinite.
Second, the benefits of social distancing (the purpose of the “lockdown”) have already been widely established. The author himself says “Social distancing works” and “This post does not deny the effectiveness of social distancing or quarantine for COVID-19.” The question is whether everyone needs to be locked down or just vulnerable populations. There are absolutely models that looked at this (See for example this influential study that had an important role in convincing both US and UK officials to take immediate action: https://www.imperial.ac.uk/…/report-9-impact-of-npis-on-co…/). They find that simply isolating vulnerable populations is not effective enough to prevent the virus from causing widespread death and overwhelmed healthcare systems.
Third, the claim that “there is essentially no further risk of overwhelming the health care system” is nonsense as discussed earlier.
Fourth, the statement “The previous models were wrong” shows a fundamental misunderstanding of what a model is and what they are for. Epidemic models are not designed for predicting the future. They are designed to explore different possible futures. When the media says “models predict that 100,000 people will die” this is a gross oversimplification. The model actually predicts something like “if people continue to interact with a particular frequency and the virus is transmitted with a particular probability and the mortality rate has a particular value and those values remain constant then there will be around 100,000 deaths”. The predictions are only as good as the input parameters. Those inputs are estimates based on the information that was available at the time. So if the predictions change it is because (a) we got more data and obtained a better estimate for the parameters or (b) our behavior changed (e.g. people adopted social distancing) and therefore the scenario the model was describing does not match our current reality. There is a famous quote by the great statistician George Box saying “All models are wrong, some models are useful.” The point is that models not meant to be perfect forecasts, they are meant to give us insight. So when the “predicted number of deaths” drops from 100000 to 60000, it does not mean that the model was wrong, it means that the inputs were updated. For example, social distancing causes people to reduce their interactions with other people. But how much? 50%? 90%? There is simply no way to know ahead of time. All that we can do is make estimates and then revise those estimates as more data comes in. I have seen some (non-scientists) people (such as the sadly misinformed author of a recent article in the nationalreview that the blogpost cites) make claims that the government should not use models to make policy. That is incredibly naïve. Without models, we would have no quantitative basis for making decisions at all. Models are used to great benefit by every branch of government. They are used to estimate tax revenues, make fiscal policy, determine whether proposed policies are a sound investment, and that is not even scratching the surface.
So instead of saying the models are wrong, we need to recognize that models are all that we have when we face unprecedented situations like this one. Models are not prophetic, but they do give us insight into the consequences of our actions. What we need now is not less models (we just need to know how to interpret them correctly). We need more! We need models to help us understand the economic and social impact of the lockdowns so that we can compare that to the benefits. Otherwise we will be left with blind speculation.
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