We are coming up on the third month in which millions of U.S. citizens have to pay rent during pandemic-induced lockdowns. This becomes more challenging since over 38 million have filed for unemployment benefits since this all began. This does not get into how many struggle financially, whether they currently have work or not. Even for those who still work, 21 million renters pay 30 percent or more of their income in rent. To help alleviate the pressures of rent, the CARES Act temporarily prohibits evictions up to 120 days for those who live in federally-owned rental units, which account for about one in four rental units in the U.S. As for the other rental units, it depends on state laws.
Eviction is a serious matter. It can result in multiple issues, including higher rates of depression and other healthcare costs, loss of one's job and possessions, higher risk of homelessness and emergency room visits (Collinson and Reed, 2018), and it can negatively impact access to credit and durable consumption over the long-term (Humphries et al., 2019). As grave as the effects of eviction are, I also worry about what the effects of a policy instrument as blunt as a ban could have. What are some of the unintended consequences that could emerge as a result of an eviction ban?
1. An eviction ban has ripple effects in the local economy. This is a point that the centrist Brookings Institution mentions. If rent checks are not paid, this would affect multiple businesses. Rent checks go to pay property taxes, insurance, utilities, mortgage to the banks, maintenance, and capital funds for upgrades. This could adversely affect banking, local government services, as well as those providing maintenance services and utilities.
2. Eviction bans do not make the costs of rent disappear. If the tenant has to pay the rent once the moratorium expires, it is going to be difficult for that tenant to catch up, particularly if their finances were precarious coming into the pandemic. If one is to propose rent forgiveness instead of merely pausing rent payments, the cost of that rent still does not go away. It is simply shifted to the landlord. As discussed in Point #1, landlords have their own costs. Even if the rent forgiveness includes a mortgage forgiveness, it would still shift the cost to banks and credit unions. Whether the rent forgiveness has a mortgage component or not, that shift towards either landlords or banks would cause liquidity issues.
3. Eviction bans could limit housing availability. It might be politically expedient to depict landlords as money-grubbing and exploiting the working class. The truth is that many landlords are individual investors (i.e., mom-and-pop landlords) exist. According to the U.S. Department of Housing and Development (HUD), 22.7 million of 48.5 million rental units, or 46.8 percent of rental units, are managed by these smaller outfits. If a significant percent of individual investors were to go under, it would limit housing supply. As I have discussed in a past analysis on housing policy, limiting housing supply would increase the cost of renting.
4. This could spell trouble for future tenants, especially lower-income tenants. Going off the previous point, increasing the cost of rent vis-à-vis supply restriction make it more difficult for those who already struggle with paying rent. On top of that, there is a related concern with lending standards. As the St. Louis Federal Reserve points out, lending standards tightened during the Great Recession, which adversely affected the lending market and access to loans (Dvorkin and Shell, 2016). When the United Kingdom was looking to ban "no-fault evictions" last year, a survey showing from the Residential Landlords Association found that 84 percent of landlords would be more selective by picking tenants of higher income. If these eviction bans continue, they could result in longer-term issues with access to apartments and other rental units.
5. In many cases, an eviction might not be necessary. Yes, there are some landlords sleazy and profit-driven enough, i.e., slumlords, where they going to apply pressure on their tenants to pay rent. At the same time, the Brookings Institution brings up a valid point: landlords have a strong incentive to keep current tenants, especially if it is a reliable tenant who will likely be working again soon. There is an uncertainty in evicting a previously reliable tenant, such uncertainty where it is arguably preferable to negotiate a reduced rate on a temporary basis than to evict. This is probably why the National Apartment Association recommends waiving late fees and working with tenants on a payment plan. The American Apartment Owners Association also found that 80 percent of apartment owners would be willing to offer forbearance.
If a unit is vacant, that means it is not bringing in any rent. This will be even more true if eviction bans result in the tightening of rental standards (See Point #4), and if a mom-and-pop landlord is running the operation (See Point #3). There are costs to bringing in a new tenant and preparing an apartment for a new tenant, not to mention that social distancing guidelines will be yet another obstacle.
Conclusion: Eviction comes with serious long-term ramifications. At the same time, I worry that eviction bans come with their own serious long-term ramifications, ranging from reduced housing supply, increased rent, and adverse effects in multiple markets that could hamper economic recovery. That is why I would prefer something such as federal housing assistance over eviction bans or repealing such onerous policies as land-use regulation and rent control. Even better, how about ending the lockdowns so we could get people back to work so they can pay their rent?
As Reason Magazine brings up, market economies exist with the underpinning of supply and demand. A general adherence to that has brought us having as affluent of an economy as we have now. As unprecedented as this situation is, the last thing I would want to happen is to make a bad situation worse.
The political and religious musings of a Right-leaning, libertarian, formerly Orthodox Jew who emphasizes rationalism, pragmatism, common sense, and free, open-minded thought.
Tuesday, May 26, 2020
Friday, May 15, 2020
The Federal Government Has No Business Bailing Out State Governments, Especially With Coronavirus as a Pretext
As if it were not enough that Congress passed a stimulus bill (the CARES Act) that exceeded $2.1 trillion, the House now wants to pass another $3 trillion bill: Health and Economic Recovery Emergency Solutions (HEROES) Act. If the HEROES Act passes, it would nearly double the $3.6 trillion Congress has spent since mid-March. Part of the HEROES Act is the Coronavirus State Fiscal Relief Fund, which would be to the tune of $540 billion. The purpose of this Fund is to provide aid to states that are financially struggling due to the unanticipated costs of coronavirus. As nice as it might sound to help states in need during this pandemic, this is a deficient policy response for a few reasons.
1. The aid does not address coronavirus-related costs. If you look at the language of the HEROES Act, it states that the funds are available "for making payments to States, territories, and tribal governments for any purpose (own emphasis added)." This is essentially unrestricted aid that does not directly respond to costs incurred because of the pandemic. This is not coronavirus aid or relief; it is a bailout to state governments.
2. States already have rainy-day funds. As the Tax Foundation illustrates (see below), states have rainy day funds. Rainy day funds exist precisely for when such unforeseen circumstances as this pandemic happen. It is reassuring that rainy day funds fared better now than they did before the Great Recession (Pew Charitable Trusts). Plus, Congress already provided $150 billion to states in coronavirus-related aid in the CARES Act to supplement its rainy day funds.
If you are a government official that is worried about your coffers, perhaps it is time to reconsider the lockdowns. Since the current economic downturn is caused by suspending various forms of economic activity, it is possible that such funding could shield states from the costs of implementing lockdowns, thereby delaying economic recovery.
3. The HEROES Act would continue to reward fiscal mismanagement. The unrestricted nature of the aid combined with the fungible nature of money would make the Fund a de facto bailout of debt primarily created by burgeoning pension costs and retiree health costs (Pew Charitable Trusts). As the Wharton School of Business at Penn State mentions, the pension issue has been around for decades. Much like I brought up with the U.S. Postal Service earlier this week, the problems of state governments predate the COVID-19 pandemic.
According to another report from Pew Charitable Trusts, the states that managed their funds best are the ones who took their actuaries' advice, as well as cutting benefits and increasing contributions when needed. How fair is it for states who exercise fiscal discipline to pay for those who do not? My home state of Illinois is a good example. Out of the $33.6 billion it requested for its state budget (the remaining $6.4 for UI benefits), only $2 billion [for Medicaid benefits] would have been for pandemic-related expenditures.
To reiterate, funding has been provided to address the immediate concerns brought on by the pandemic. Anything beyond that would be imprudent.
4. Past bailouts of state government created greater and more inefficient government spending. In response to the market turndown of 2002-2003, the Bush Administration approved $20 billion in state government bailouts through the Jobs and Growth Tax Relief Reconciliation Act of 2003. Instead of getting finances under order, state spending increased by 33 percent from 2003 to 2008 (Norcross, 2010).
State budgeting did not fare better under the Great Recession. The American Recovery and Reinvestment Act (ARRA) allocated $300 billion to state governments as a bailout. About $50 billion was meant for education systems stabilization. But as the Right-leaning Heritage Foundation points out, most of that education funding was not for stabilizing, but for expanding staff, especially non-teaching staff. In spite of the $90 billion in ARRA Medicaid funds meant to be a one-time provision, 28 states built in their 2011 budget the expectation of higher Medicaid funding (Norcross, 2010). According to the Federal Reserve Bank of San Francisco, the $70 billion allocated towards transportation projects were skewed towards state with lower unemployment, i.e., states who needed the funding less (Wilson, 2009).
Through these bailouts, we see the federal government becoming more responsible for state budgets. The percent of state funds from federal revenue grew from 26.3 percent in 2001 to 32.4 percent in 2017 (Pew Charitable Trusts). All this moral hazard done is created greater incentive for states to rack up unfunded liabilities while depending on the federal government to solve their problems.
5. This would create fiscal pain and a disturbing precedent for the future. If we throw billions of unrestricted dollars to state governments now, it would create moral hazard of a high magnitude because it would create poor incentives while doing nothing to solve state budgetary issues. It would allow for the federal government's increasing role in future state-level government affairs, which would further erode state sovereignty. More to the point, past bailouts have already eroded fiscal discipline for many states and have made state budgets less resilient in future crises. Plus, it would push the U.S. federal debt closer to a level of disaster because it would mean we would pay interest in the long-term.
Ultimately, Congress' response should be towards the temporary and targeted approach to the pandemic, not by creating perverse incentives that will affect budgeting processes for years to come.
1. The aid does not address coronavirus-related costs. If you look at the language of the HEROES Act, it states that the funds are available "for making payments to States, territories, and tribal governments for any purpose (own emphasis added)." This is essentially unrestricted aid that does not directly respond to costs incurred because of the pandemic. This is not coronavirus aid or relief; it is a bailout to state governments.
2. States already have rainy-day funds. As the Tax Foundation illustrates (see below), states have rainy day funds. Rainy day funds exist precisely for when such unforeseen circumstances as this pandemic happen. It is reassuring that rainy day funds fared better now than they did before the Great Recession (Pew Charitable Trusts). Plus, Congress already provided $150 billion to states in coronavirus-related aid in the CARES Act to supplement its rainy day funds.
If you are a government official that is worried about your coffers, perhaps it is time to reconsider the lockdowns. Since the current economic downturn is caused by suspending various forms of economic activity, it is possible that such funding could shield states from the costs of implementing lockdowns, thereby delaying economic recovery.
3. The HEROES Act would continue to reward fiscal mismanagement. The unrestricted nature of the aid combined with the fungible nature of money would make the Fund a de facto bailout of debt primarily created by burgeoning pension costs and retiree health costs (Pew Charitable Trusts). As the Wharton School of Business at Penn State mentions, the pension issue has been around for decades. Much like I brought up with the U.S. Postal Service earlier this week, the problems of state governments predate the COVID-19 pandemic.
According to another report from Pew Charitable Trusts, the states that managed their funds best are the ones who took their actuaries' advice, as well as cutting benefits and increasing contributions when needed. How fair is it for states who exercise fiscal discipline to pay for those who do not? My home state of Illinois is a good example. Out of the $33.6 billion it requested for its state budget (the remaining $6.4 for UI benefits), only $2 billion [for Medicaid benefits] would have been for pandemic-related expenditures.
To reiterate, funding has been provided to address the immediate concerns brought on by the pandemic. Anything beyond that would be imprudent.
4. Past bailouts of state government created greater and more inefficient government spending. In response to the market turndown of 2002-2003, the Bush Administration approved $20 billion in state government bailouts through the Jobs and Growth Tax Relief Reconciliation Act of 2003. Instead of getting finances under order, state spending increased by 33 percent from 2003 to 2008 (Norcross, 2010).
State budgeting did not fare better under the Great Recession. The American Recovery and Reinvestment Act (ARRA) allocated $300 billion to state governments as a bailout. About $50 billion was meant for education systems stabilization. But as the Right-leaning Heritage Foundation points out, most of that education funding was not for stabilizing, but for expanding staff, especially non-teaching staff. In spite of the $90 billion in ARRA Medicaid funds meant to be a one-time provision, 28 states built in their 2011 budget the expectation of higher Medicaid funding (Norcross, 2010). According to the Federal Reserve Bank of San Francisco, the $70 billion allocated towards transportation projects were skewed towards state with lower unemployment, i.e., states who needed the funding less (Wilson, 2009).
Through these bailouts, we see the federal government becoming more responsible for state budgets. The percent of state funds from federal revenue grew from 26.3 percent in 2001 to 32.4 percent in 2017 (Pew Charitable Trusts). All this moral hazard done is created greater incentive for states to rack up unfunded liabilities while depending on the federal government to solve their problems.
5. This would create fiscal pain and a disturbing precedent for the future. If we throw billions of unrestricted dollars to state governments now, it would create moral hazard of a high magnitude because it would create poor incentives while doing nothing to solve state budgetary issues. It would allow for the federal government's increasing role in future state-level government affairs, which would further erode state sovereignty. More to the point, past bailouts have already eroded fiscal discipline for many states and have made state budgets less resilient in future crises. Plus, it would push the U.S. federal debt closer to a level of disaster because it would mean we would pay interest in the long-term.
Ultimately, Congress' response should be towards the temporary and targeted approach to the pandemic, not by creating perverse incentives that will affect budgeting processes for years to come.
Monday, May 11, 2020
The U.S. Postal Service Was Screwed Before Coronavirus: The Latest GAO Report and a Need for Postal Privatization
When the Post Office was enumerated in the Constitution (Article I, Section 8, Clause 7), it is understandable why it would merit constitutional protection. Being able to communicate across the country was difficult for much of U.S. history. The telegraph and telephone helped advance communications in the U.S., but there was still a place for the postal service. Once the digital age set in and the Internet became ubiquitous, the U.S. Postal Service (USPS) has become increasingly irrelevant and unsustainable.
The Government Accountability Office (GAO) report that was released last week provides just how irrelevant and unsustainable the USPS is. And to think I'm saying that as someone whose grandfather worked at the USPS for most of his adult life! The title of the report, "Congressional Action Is Essential to Enable a Sustainable Business Model," says a lot. Why does it not have a sustainable business model in the first place? The GAO report found that the USPS lost $78 billion from 2007 to 2019. As the GAO figure below shows, the main driver of said debt is workers' benefits, whether in the form of unfunded liabilities for retirement benefits, unfunded liabilities for health benefits, or workers' compensation.
The other major challenge that USPS faces is declining mail volumes. First-class mail has declined 44 percent from its 2006 peak (GAO, p. 8-9). As the Cato Institute points out in its 2019 analysis of the post office (see chart below), mail has declined substantially. What makes that more upsetting is that most of the items being delivered by the USPS is marketing mail. Junk mail and debt are the USPS' main contributions to society. Imagine that!
I have previously analyzed the USPS in 2017 and in 2011, so it's no surprise where I land on this topic. As a recap both of this blog entry and to provide a summary of past blog entries, labor costs are too high. The USPS is a tax-exempt entity with monopolistic power in first-class and standard mail, and it still cannot create a net profit. Delivery routes plateau and Saturday service remains while mail volume declines. The price of stamps went up 10 percent in 2019, but the gap between revenue and expenses widened. There is a reluctance to close post offices, in spite of the notable decline of foot traffic. Most of the USPS' deliveries are junk mail. The divergence between mail delivered and number of employees is notable and close to eye-popping.
It is true that the pandemic is putting pressure on the USPS. COVID-19 and the subsequent lockdowns have caused a decline in mail volume, as well as generating a net operation loss. This is why the Democrats are seeking $25 billion to revive the USPS. Conversely, what we see is that these trends predate the pandemic by years. As Cato Institute expert Chris Edwards brings up in his 2019 testimony to Congress on the subject, we need to work towards postal service privatization. Germany's Deutsche Post, the Dutch PostNL, Japan Post, CTT Correios de Portugal, and the United Kingdom's Royal Mail have all gone the privatization route. Sweden and New Zealand have put their postal systems in corporate form. It is clear that relying on the USPS to contain costs while demand for its services (save package delivery) is on the decline is too much to ask since neither the USPS nor Congress can provide the flexibility required to reform the USPS. Ultimately, introducing privatization and greater competitive forces will be the best way to make the postal service vibrant and sustainable.
The Government Accountability Office (GAO) report that was released last week provides just how irrelevant and unsustainable the USPS is. And to think I'm saying that as someone whose grandfather worked at the USPS for most of his adult life! The title of the report, "Congressional Action Is Essential to Enable a Sustainable Business Model," says a lot. Why does it not have a sustainable business model in the first place? The GAO report found that the USPS lost $78 billion from 2007 to 2019. As the GAO figure below shows, the main driver of said debt is workers' benefits, whether in the form of unfunded liabilities for retirement benefits, unfunded liabilities for health benefits, or workers' compensation.
The other major challenge that USPS faces is declining mail volumes. First-class mail has declined 44 percent from its 2006 peak (GAO, p. 8-9). As the Cato Institute points out in its 2019 analysis of the post office (see chart below), mail has declined substantially. What makes that more upsetting is that most of the items being delivered by the USPS is marketing mail. Junk mail and debt are the USPS' main contributions to society. Imagine that!
I have previously analyzed the USPS in 2017 and in 2011, so it's no surprise where I land on this topic. As a recap both of this blog entry and to provide a summary of past blog entries, labor costs are too high. The USPS is a tax-exempt entity with monopolistic power in first-class and standard mail, and it still cannot create a net profit. Delivery routes plateau and Saturday service remains while mail volume declines. The price of stamps went up 10 percent in 2019, but the gap between revenue and expenses widened. There is a reluctance to close post offices, in spite of the notable decline of foot traffic. Most of the USPS' deliveries are junk mail. The divergence between mail delivered and number of employees is notable and close to eye-popping.
It is true that the pandemic is putting pressure on the USPS. COVID-19 and the subsequent lockdowns have caused a decline in mail volume, as well as generating a net operation loss. This is why the Democrats are seeking $25 billion to revive the USPS. Conversely, what we see is that these trends predate the pandemic by years. As Cato Institute expert Chris Edwards brings up in his 2019 testimony to Congress on the subject, we need to work towards postal service privatization. Germany's Deutsche Post, the Dutch PostNL, Japan Post, CTT Correios de Portugal, and the United Kingdom's Royal Mail have all gone the privatization route. Sweden and New Zealand have put their postal systems in corporate form. It is clear that relying on the USPS to contain costs while demand for its services (save package delivery) is on the decline is too much to ask since neither the USPS nor Congress can provide the flexibility required to reform the USPS. Ultimately, introducing privatization and greater competitive forces will be the best way to make the postal service vibrant and sustainable.
Labels:
Big Government,
COVID Pandemic,
Free Markets
Friday, May 8, 2020
A Libertarian Case for a Temporary, Partial Face Mask Mandate During the COVID-19 Pandemic
In a democratic society, crises are not only a stress test for our institutions, but they test how much freedom we truly have, even in a pandemic. Fear is one of the greatest enemies of freedom. In the middle of a pandemic and millions panicking, it becomes more difficult to discern which measures are legitimate precautions in which the inconvenience is justifiable and which measures encroach on our right to life, liberty, and the pursuit of happiness. Wearing a mask in public, although it is hardly the most inconvenient measure throughout this pandemic, has become symbolic of the political polarization in this country. The divide is similar to that we see in terms of who wants to keep the lockdowns going and who wants to lift them. Look at the poll results from an Ipsos poll showing the difference of 22 percentage points in mask usage between Republicans and Democrats. Those who are against the masks see those wearing masks partaking in virtue-signaling and overreacting. I heard one such individual recently ask, "If the masks are so effective, why do we need the lockdown?" Those who are for the masks see those choosing not to wear the masks as reckless individuals who are part of the problem. Below are two memes to illustrate the pro-mask side.
Part of what makes the face mask debate confusing is the inconsistent and contradictory guidance that is out there. In late February, the Surgeon General advised against face masks before changing his mind because of all of the pre-symptomatic and asymptomatic cases of COVID-19. The CDC subsequently recommended in early April that people wear masks when going out. If that were not enough, the World Health Organization (WHO) in early April said that "no evidence that wearing a mask (whether medical or other types) by healthy persons in the wider community setting, including universal community masking, can prevent them from infection with respiratory viruses, including COVID-19." The advice of the Belgian Federal Public Service of Health is that masks have value when in a hospital or laboratory, but generally wearing it in public provides no value. Professor Ben Cowling at the Hong Kong School of Public Policy opines that masking the healthy would unlikely help stop the spread of COVID-19. If the science were really that intuitive and straight-forward, I don't think there would be need for the debate. That is why trying to get past the confusion is helping in guiding public policy and best practices in these matters.
Given that COVID-19 is primarily spread through respiratory droplets, it would make sense that masks could stop the spread of COVID-19. Also, the number of asymptomatic or pre-symptomatic individuals could provide a basis for the masks. However, as McGill University points out, there is little evidence that non-medical cloth masks work. According to Professor Paul Hunter from Britain University, it is difficult to conduct a proper clinical trial because of the number of variables involved. Research on previous respiratory diseases does not provide us definitive answers, as we see below.
Research Supporting Masks
At a time we need clarity, we have confusion and contradictory findings within the research for masks. Rather than say "a case could be made in either direction," let us not forget that poor evidence quality is not the same as no evidence. There is a stronger case to be made for N95 masks and surgical masks than there is for cloth face masks. Additionally, as Johns Hopkins infectious disease specialist Dr. Amesh Adalja brings up, COVID-19 is not airborne; you need droplets to transmit it from one person to another. Consequently, there is a stronger argument for face masks in closed spaces indoors (e.g., the grocery store, public transit) than is for the outdoors. As a matter of fact, the benefits of going outside without a mask outweigh the potential costs, especially since germs simultaneously dilute and decay with outdoor air.
Another point worth mentioning is that there is more evidence, especially for cloth face masks, that face masks slow the rate of transmission than there is evidence that they prevent catching the respiratory disease. Failing to meet one of those criteria does not disqualify the argument for masks. As a matter of fact, I made an argument about having a brief waiting period for purchasing a gun. Although there really isn't evidence that waiting periods lower the homicide rate, they do lower the suicide rate, which is why I was okay with a temporary inconvenience in that instance.
As someone who identifies as libertarian, I have argued on numerous occasions that one should be able to live their life as long as they are not harming others. Believe me when I understand the sentiment behind "life, liberty, and pursuit of happiness." At the same time, when there is an overriding public health concern in which your decisions could very well affect another, that is a different discussion. Back in 2013, I laid out the case for a partial smoking ban [in indoor public places] on the grounds that second-hand smoke is a negative externality that affects other people's health.
I can make a similar argument for face masks in the middle of this pandemic, and I am not the only libertarian to do so. Human beings have control over one's actions, but we do not have control over what pathogens do, whether we contract a certain pathogen, or whether we transmit a certain pathogen. Unlike the unnecessary lockdowns, there is not a clear economic cost. As a matter of fact, one study shows that face masks actually contribute to a net positive economic benefit (Tracht et al., 2012). As far as convenience goes, face masks are nowhere in the magnitude of the lockdowns causing people to stay at home and lose their livelihoods. There is a clear public health justification that justifies wearing masks: stop the pandemic from getting worse.
If an individual voluntarily decides to wear a face mask, I certainly don't take issue. If a business voluntarily decides to require a face mask for entry to its establishment, I don't mind. After all, "no shirt, no shoes, no service" has existed for quite some time. Where I struggle a bit is whether there should be a mandate.
As the Foundation for Economic Education (FEE) reminds us, "Good ideas generally don't require force." Normally, I would agree and say that voluntary wearing of masks would be adequate. At the same time, communications from public health officials has been unhelpful and confusing, so FEE's argument doesn't work so well in this case. I also have concerns about enforcement, not to mention the poor evidence quality for the face masks (particularly cloth face masks).
Even so, I think my bottom line is the following. As you can imagine, I am generally not a fan of government mandates. After all, look at all of the government regulations that existed prior to the pandemic that made our response to COVID-19 worse than it needed to be. The research quality on face masks is far from being as definitive as I would like. At the same time, the lack of economic cost and potential public health benefits outweigh the inconvenience of having to wear a mask. As such, I think there is an argument to be made for a partial face mask mandate for certain indoor spaces. I would also caveat it by saying that this temporary mandate should be in place as long as the rate of transmission [R0] is still high (we can argue about that, but I would say any R0 greater than 1.0, but maybe a bit lower to be sure).
Face masks are not a silver bullet. They are not going to make the pandemic go away, but they are part of the goal of flattening the curve in order to slow the rate of transmission and to not overwhelm hospitals. Masks should be accompanied with other such measures as washing your hands and social distancing. Under normal circumstances, I would sympathize with the anti-authoritarian sentiments and say "my body, my choice" or "don't tell me what to do with my life." However, these are far from normal times. We are in the middle of a pandemic, and pathogens do not play by the same rules as we do. There could end up being some disconcerting policy decisions that would make me leery, but wearing face masks is not a slippery slope into an Orwellian dystopia. Defiantly not wearing masks is not a sign of freedom. Freedom comes with choice, but it also comes with the responsibility for the consequences of your actions. In this case, we need to wear masks to make sure that we do not violate another's right to life, liberty, and pursuit of happiness. Let's wear the masks and slow the transmission of COVID-19 so we can resume some semblance of normal living soon.
Part of what makes the face mask debate confusing is the inconsistent and contradictory guidance that is out there. In late February, the Surgeon General advised against face masks before changing his mind because of all of the pre-symptomatic and asymptomatic cases of COVID-19. The CDC subsequently recommended in early April that people wear masks when going out. If that were not enough, the World Health Organization (WHO) in early April said that "no evidence that wearing a mask (whether medical or other types) by healthy persons in the wider community setting, including universal community masking, can prevent them from infection with respiratory viruses, including COVID-19." The advice of the Belgian Federal Public Service of Health is that masks have value when in a hospital or laboratory, but generally wearing it in public provides no value. Professor Ben Cowling at the Hong Kong School of Public Policy opines that masking the healthy would unlikely help stop the spread of COVID-19. If the science were really that intuitive and straight-forward, I don't think there would be need for the debate. That is why trying to get past the confusion is helping in guiding public policy and best practices in these matters.
Given that COVID-19 is primarily spread through respiratory droplets, it would make sense that masks could stop the spread of COVID-19. Also, the number of asymptomatic or pre-symptomatic individuals could provide a basis for the masks. However, as McGill University points out, there is little evidence that non-medical cloth masks work. According to Professor Paul Hunter from Britain University, it is difficult to conduct a proper clinical trial because of the number of variables involved. Research on previous respiratory diseases does not provide us definitive answers, as we see below.
Research Supporting Masks
- A randomized trial from Berlin shows that household transmission of influenza can be reduced by face masks (Suess et al., 2012).
- A systematic review from Cambridge said that there is some evidence of the effectiveness of wearing masks to protect others, but fewer data to support the idea that it prevents becoming infected (Cowling et al., 2010).
- Another systematic review shows how N95 and surgical masks are the among the most consistently successful of physical interventions for preventing respiratory infections (Jefferson et al., 2011; also see Jefferson et al., 2008 and Leung et al., 2020).
- A couple of dozen laboratory simulations show that N95 and surgical masks can prevent viral particles from getting through (Smith et al., 2016). However, this study also showed the N95 masks do not fare better than surgical masks.
- One study found that surgical masks are three times as effective as home-made cloth masks, but that cloth masks are still effective in preventing spread (Davies et al., 2013).
- Tangentially, I could cite an additional concern about moral hazard since a false sense of security could either incentivize abandoning other preventative measures or give people greater incentive to go to places where they could be more likely to contract COVID-19. At the same time, no research suggests that moral hazard would play a strong enough role to argue against face masks.
Research Not Supporting Masks
- A randomized control trial goes as far as saying that there is no effect of N95 masks (MacIntyre et al., 2010).
- One study shows that there a 97 percent penetration rate of cloth masks, as opposed to the 44 percent for surgical masks. (MacIntyre et al., 2015). This study also points out that cloth masks carry the extra risk of trapping virus-containing droplets.
- Another study shows that a filtering face piece (FFP) mask is about 50 times more effective at protection than a cloth mask (van der Sande et al., 2008), which implies that cloth masks cannot be more than two percent effective.
- A randomized trial of mask use among college students from the 2006-07 influenza season. While there was a reduction in influenza, the authors could not contribute it to mask usage alone (Aiello et al., 2010).
- A paper as recently as this April used 14 randomized trials. It found that there was no reduction in influenza-like cases for influenza in the general population, nor amongst healthcare workers (Jefferson et al, 2020).
- It also depends on how often the masks are used and washed. If they are not laundered regularly, it could actually be worse to wear a mask (MacIntyre et al., 2020).
- A randomized open-label trial of pilgrims attending Mecca in Saudi Arabia found no difference in viral respiratory infection between mask wearers and those who weren't wearing masks (Alfelali et al., 2019).
At a time we need clarity, we have confusion and contradictory findings within the research for masks. Rather than say "a case could be made in either direction," let us not forget that poor evidence quality is not the same as no evidence. There is a stronger case to be made for N95 masks and surgical masks than there is for cloth face masks. Additionally, as Johns Hopkins infectious disease specialist Dr. Amesh Adalja brings up, COVID-19 is not airborne; you need droplets to transmit it from one person to another. Consequently, there is a stronger argument for face masks in closed spaces indoors (e.g., the grocery store, public transit) than is for the outdoors. As a matter of fact, the benefits of going outside without a mask outweigh the potential costs, especially since germs simultaneously dilute and decay with outdoor air.
Another point worth mentioning is that there is more evidence, especially for cloth face masks, that face masks slow the rate of transmission than there is evidence that they prevent catching the respiratory disease. Failing to meet one of those criteria does not disqualify the argument for masks. As a matter of fact, I made an argument about having a brief waiting period for purchasing a gun. Although there really isn't evidence that waiting periods lower the homicide rate, they do lower the suicide rate, which is why I was okay with a temporary inconvenience in that instance.
As someone who identifies as libertarian, I have argued on numerous occasions that one should be able to live their life as long as they are not harming others. Believe me when I understand the sentiment behind "life, liberty, and pursuit of happiness." At the same time, when there is an overriding public health concern in which your decisions could very well affect another, that is a different discussion. Back in 2013, I laid out the case for a partial smoking ban [in indoor public places] on the grounds that second-hand smoke is a negative externality that affects other people's health.
I can make a similar argument for face masks in the middle of this pandemic, and I am not the only libertarian to do so. Human beings have control over one's actions, but we do not have control over what pathogens do, whether we contract a certain pathogen, or whether we transmit a certain pathogen. Unlike the unnecessary lockdowns, there is not a clear economic cost. As a matter of fact, one study shows that face masks actually contribute to a net positive economic benefit (Tracht et al., 2012). As far as convenience goes, face masks are nowhere in the magnitude of the lockdowns causing people to stay at home and lose their livelihoods. There is a clear public health justification that justifies wearing masks: stop the pandemic from getting worse.
If an individual voluntarily decides to wear a face mask, I certainly don't take issue. If a business voluntarily decides to require a face mask for entry to its establishment, I don't mind. After all, "no shirt, no shoes, no service" has existed for quite some time. Where I struggle a bit is whether there should be a mandate.
As the Foundation for Economic Education (FEE) reminds us, "Good ideas generally don't require force." Normally, I would agree and say that voluntary wearing of masks would be adequate. At the same time, communications from public health officials has been unhelpful and confusing, so FEE's argument doesn't work so well in this case. I also have concerns about enforcement, not to mention the poor evidence quality for the face masks (particularly cloth face masks).
Even so, I think my bottom line is the following. As you can imagine, I am generally not a fan of government mandates. After all, look at all of the government regulations that existed prior to the pandemic that made our response to COVID-19 worse than it needed to be. The research quality on face masks is far from being as definitive as I would like. At the same time, the lack of economic cost and potential public health benefits outweigh the inconvenience of having to wear a mask. As such, I think there is an argument to be made for a partial face mask mandate for certain indoor spaces. I would also caveat it by saying that this temporary mandate should be in place as long as the rate of transmission [R0] is still high (we can argue about that, but I would say any R0 greater than 1.0, but maybe a bit lower to be sure).
Face masks are not a silver bullet. They are not going to make the pandemic go away, but they are part of the goal of flattening the curve in order to slow the rate of transmission and to not overwhelm hospitals. Masks should be accompanied with other such measures as washing your hands and social distancing. Under normal circumstances, I would sympathize with the anti-authoritarian sentiments and say "my body, my choice" or "don't tell me what to do with my life." However, these are far from normal times. We are in the middle of a pandemic, and pathogens do not play by the same rules as we do. There could end up being some disconcerting policy decisions that would make me leery, but wearing face masks is not a slippery slope into an Orwellian dystopia. Defiantly not wearing masks is not a sign of freedom. Freedom comes with choice, but it also comes with the responsibility for the consequences of your actions. In this case, we need to wear masks to make sure that we do not violate another's right to life, liberty, and pursuit of happiness. Let's wear the masks and slow the transmission of COVID-19 so we can resume some semblance of normal living soon.
Labels:
COVID Pandemic,
Face Masks,
Healthcare,
Libertarian Ideology
Tuesday, May 5, 2020
Why We Need to Start Lifting Coronavirus Lockdowns Sooner Rather than Later
You know that we continue to live in an age of political polarization when even a pandemic is politicized. During this pandemic, there are two main sides on the lockdown debate: those who want to keep the lockdowns going ("Closers") and those who want to lift the lockdowns ("Openers"). Openers are concerned about the economic damage being done to the millions unemployed and worry that the benefits don't justify the costs of the lockdown. Closers are concerned that opening the economy would result in a major uptick in COVID-19 cases, overburden the system, and make a bad situation worse.
For those who hold a polarizing view, one side has the tendency to see the other side not only as wrong, but as evil and morally deficient. There are Openers who think the Closers are either too oblivious to notice the economic effects or are too privileged to care about the newly unemployed because they have the convenience of being able to stay at home without their jobs or livelihoods being at risk. It can come off as callous and supporting the suffering of millions. There are Closers who think that Openers are too selfish, with little to no disregard for others (especially the elderly), and only care about money. The more belligerent Closers view Openers as the moral equivalent of murderers.
In addition to vilification of an opposing side, fear has also become even more widespread during the pandemic, which is saying something. The fear of Openers is that the economy will be so damaged that it will take years to recover and that millions will suffer in poverty and struggle simply to survive. This phenomenon will end up being more pronounced in the developing world. The fear of Closers is that they could catch COVID-19 and die. Alternatively, Closers fear that because many infected with COVID-19 are asymptomatic, they can spread the virus to others without knowing it, which could unknowingly and unintentionally harm another. Closers also have the fear that opening the economy at this moment would create an even worse problem than what we are going through right now.
During my time on the high school debate team, one has to be able to argue the other side in addition to one's own. If you cannot do so, you truly do not understand the topic at hand. I have been tracking the severity of the virus to make sure that my reaction to COVID-19 was neither an overreaction nor an under-reaction (see my March and April synopses). What I know is that COVID-19 is an upper respiratory infection with non-specific symptoms. It is not particularly fatal relative to past pandemics (see below), but it started off with an adequately high rate of transmission. To make it more challenging to fight, it can take two weeks to show symptoms (assuming one is not asymptomatic). Unlike SARS, the world was unable to contain COVID-19, which has in part led to the mess we are in.
While I understand the concerns of Closers and while I understand that each jurisdiction should have a different policy prescription based on their local reality regarding COVID-19, I consider myself more of an Opener who thinks that gradually opening the economy for most jurisdictions is something we need. You might be wondering how I came to that conclusion. Well, here is the list of reasons and considerations I came up with for gradually reopening the economy:
Postscript
As we receive more data, we see that COVID-19 is nowhere near as lethal as initially projected. All the while, economic damage has predictably been gargantuan. What makes that scarier is that we have not begin to see the damage and unintended consequences that the lockdowns have caused, whether to the economy, individual health, civil liberties, or the social unrest it will end up causing. Panic needs to replaced with data-informed decisions. While COVID-19 is serious, it is also true that fear has been misleading the public in terms of creating a proportionate response.
What does that response entail? I brought up a few ideas last month, but increasing testing capacity to isolate hotspots is vital. Expanding medical capacity would also help. In terms of gradually opening the economy, we should go beyond thinking in terms of "essential" and "non-essential" jobs. We should also think of it in terms of level of risk and use standard risk management to think of it in terms of "low, medium, and high risk." Laws requiring masks in public indoor venues, capacity limits in restaurants and bars, and a recommendation for keeping a distance of six feet also seem like good ideas. There are policy options that exist between "lock everything down" and "do nothing." States are starting to realize that. Such states as Texas, Florida, and Georgia have started with a partial reopening. Even the Governor of New York, which was the most heavily hit state, realizes that lockdowns are not an indefinite solution, which is why he released a recovery plan earlier this week. Now is the time to start implementing those policy alternatives so we can minimize both the public health and economic effects.
For those who hold a polarizing view, one side has the tendency to see the other side not only as wrong, but as evil and morally deficient. There are Openers who think the Closers are either too oblivious to notice the economic effects or are too privileged to care about the newly unemployed because they have the convenience of being able to stay at home without their jobs or livelihoods being at risk. It can come off as callous and supporting the suffering of millions. There are Closers who think that Openers are too selfish, with little to no disregard for others (especially the elderly), and only care about money. The more belligerent Closers view Openers as the moral equivalent of murderers.
In addition to vilification of an opposing side, fear has also become even more widespread during the pandemic, which is saying something. The fear of Openers is that the economy will be so damaged that it will take years to recover and that millions will suffer in poverty and struggle simply to survive. This phenomenon will end up being more pronounced in the developing world. The fear of Closers is that they could catch COVID-19 and die. Alternatively, Closers fear that because many infected with COVID-19 are asymptomatic, they can spread the virus to others without knowing it, which could unknowingly and unintentionally harm another. Closers also have the fear that opening the economy at this moment would create an even worse problem than what we are going through right now.
During my time on the high school debate team, one has to be able to argue the other side in addition to one's own. If you cannot do so, you truly do not understand the topic at hand. I have been tracking the severity of the virus to make sure that my reaction to COVID-19 was neither an overreaction nor an under-reaction (see my March and April synopses). What I know is that COVID-19 is an upper respiratory infection with non-specific symptoms. It is not particularly fatal relative to past pandemics (see below), but it started off with an adequately high rate of transmission. To make it more challenging to fight, it can take two weeks to show symptoms (assuming one is not asymptomatic). Unlike SARS, the world was unable to contain COVID-19, which has in part led to the mess we are in.
While I understand the concerns of Closers and while I understand that each jurisdiction should have a different policy prescription based on their local reality regarding COVID-19, I consider myself more of an Opener who thinks that gradually opening the economy for most jurisdictions is something we need. You might be wondering how I came to that conclusion. Well, here is the list of reasons and considerations I came up with for gradually reopening the economy:
- The worst-case scenario death toll has not come to pass. As of date, there have been about 70,000 recorded COVID-related deaths in the U.S. People dying in a pandemic is tragic, and I'm not here to minimize those who lost loved ones. At the same time, let's remember what predictions we were looking at that scared us to go into lockdown mode in the first place. The CDC's worst-case scenario was a death toll of 1.7 million. The Imperial College model was even scarier by estimating 2.2 million deaths in the U.S. By the way, this is the same model that scared the United Kingdom so badly that it went from a herd immunity approach to lockdown. The Imperial College's inflexible model has not been updated, made a hair-raising prediction with the unrealistic assumption that we would sit on our hands and do nothing, and has since been debunked.
- Contrast that to the University of Washington model, which is the model that the White House uses, is updated regularly, and much more accurately predicted the amount of deaths than Imperial College. This model shows that 45 states are past the peak of this COVID-19 wave (i.e., all but Arkansas, Utah, Kansas, and the Dakotas). Up until yesterday, the University of Washington was projecting 72,433 deaths. They have since increased their estimate to 134,475 deaths. In spite of the upward revision, 134,475 deaths would be 92 percent lower than the CDC's worst-case scenario. If a second wave of the same magnitude were to hit, that would still be 84.2 percent lower than the CDC's worst-case scenario. It might come off as callous to view the death toll in such terms, but the reality is that we're in the middle of a pandemic. The goal is not zero deaths because we are well past that point. The goal is "the fewer deaths, the better."
- Early estimates likely overestimated COVID-19's fatality. Early estimates put the mortality rate of COVID-19 somewhere between 2 percent to 3.4 percent (see Rajgor et al., 2020). Using the case fatality rate (CFR), which is the number of confirmed cases divided by the number of deaths, in this instance skews the fatality rate upward because it only counts those who have been tested. The current testing comes with a selection bias by omitting asymptomatic or mild cases of COVID-19, which makes the fatality rate seem significantly higher than it actually is. Thankfully, expansion of molecular testing (seeing who currently has COVID-19) and use of serological testing (seeing who had COVID-19) vis-à-vis randomized testing has provided a more accurate picture with an infection fatality rate (IFR). With the preliminary IFR data available, the IFR ranges from 0.1 percent to 0.6 percent. While COVID-19 is likely to be more deadly than influenza, which has a fatality rate of 0.1 percent, it is nowhere near as deadly as initially predicted. COVID-19 is also not as deadly as other coronaviruses. SARS has a fatality rate of 8.6 percent, whereas MERS has a fatality rate of 30 to 40 percent. The lockdowns were made with an assumption about a fatality rate being anywhere between three and thirty-four times higher than what current data are showing. Knowing that COVID-19 is not as fatal as initially perceived weakens the argument for continued lockdowns.
- Flattening the curve has succeeded. The idea of "flattening the curve" is not to eliminate the disease. Flattening the curve is supposed to slow the rate of infection and spread it out over time in order to not overwhelm our healthcare systems, as well as prevent deaths specific to there not being enough available medical care to fight COVID-19. As such, the main metric in making sure that the curve is flattened is hospital capacity (e.g., having adequate number of staff, hospital beds, ventilators). As long as hospitals have the capacity to deal with the influx of patients, the argument for the lockdowns becomes diminished. If one moves the goalpost from "flatten the curve" to "we can't lift the lockdowns until there are very few or no deaths" or "we need a vaccine before doing so," all that has been proven is that the lockdowns were enacted under false pretenses.
- You can see data from health analytics firm Definitive Healthcare or from the University of Washington for those metrics.
- Side note: If we look at the state of New York, the U.S. state that was most heavily hit by COVID-19, Governor Andrew Cuomo was asking Trump for 40,000 ventilators. The University of Washington estimated that only 6,000 ventilators would be needed in New York. More interestingly, Cuomo actually sent ventilators to Maryland and Michigan because there were so many.
- The lockdowns are killing the economy. While the number of deaths has remained well below what doomsayers and their epidemiological models were predicting, the economic damage that I saw coming from a mile away has become abundantly clear in the past few weeks. The extent of the economic damage depends on the length and severity of the lockdowns. Each day that we spend in lockdown causes billions of dollars and increases the likelihood that millions of people around the world will permanently lose their jobs, thereby subjugating them to poverty-stricken conditions.
- There have been over 30 million who filed unemployment claims in the past six weeks. While some will be able to go back to work once the lockdowns are over, the Congressional Budget Office's (CBO) latest projection shows that unemployment will be at an annual average of 10.1 percent in 2021.
- The real GDP for Q1 2020 decreased at an annualized rate of 4.8 percent. Since the lockdowns were not taking place until the end of Q1, we are really not going to see the full economic damage until Q2 figures are released. Although I don't have Q2 figures (obviously since we are in Q2), it is a safe bet that we are in a recession. How long and how deep of a recession will depend on how long these lockdowns last.
- Federal Reserve President James Bullard estimates that the U.S. economy is hemorrhaging $25 billion a day, which means a 40-day quarantine would cost the U.S. $1 trillion.
- Manufacturing output is at its lowest 5.4 percent in March, which is the biggest plunge in over 70 years. This will hit small businesses in particular. A 2016 study from the J.P. Morgan Chase Foundation found that the median amount of cash reserves that a small business has would only last 27 days.
- A Rand Corporation study calculates that 73 percent of workers are going to experience an income decline of some sort (Strong and Welburn, 2020).
- If people cannot find jobs in the regular economy, they will go to the black market to make sure they can feed their families. During the Great Recession, the underground economy accounted for about 20 percent of the Spanish and Italian GDP. The increase of crime, violence, social unrest, and human rights abuses that take place in the black market should be enough to warrant avoiding this outcome.
- Higher unemployment among health care workers. This seems counterintuitive since we are in a pandemic. You would think there would be a high enough demand for health services to keep health care workers employed. At the same time, the ironic truth is that healthcare workers are being furloughed or laid off. As of April 7, 230 hospitals already started furloughing. I can only imagine there being more layoffs and furloughs since then. But how can this be? We did not end up overwhelming the healthcare system in most places in the U.S. There was actually plenty of hospital capacity. What ended up happening is that non-essential medical procedures were postponed. Because there is such an excess capacity and hospitals are financially hurting because they cannot bring in additional revenue with the "non-essential" medical procedures, hospitals have needed to cut staff. If we keep going, not only do we undermine health care capability to fight off other diseases, but we make it more difficult to fight COVID-19 both in this wave and in the possibility of a second wave.
- We are neglecting non-COVID healthcare at our own risk. Other health care problems don't take a vacation simply because COVID-19 exists. A few things to point out regarding the healthcare-related effects of a lockdown and the resulting recession:
- As a meta-study from the National Institutes of Health (NIH) found, health indicators that took a downward turn during the Great Recession include morbidity, suicidal behavior, psychological distress, fertility, and self-related health (Margerison-Zilko et al., 2016). The reason I bring this up is that because we are in a lockdown-induced economic downturn that is most probably worse than the Great Recession.
- Another study from the Lancet found that higher unemployment due to the 2007-2009 financial crisis caused 260,000 excess cancer deaths worldwide (Maruthappu et al., 2016).
- Calls to mental health hotlines have increased almost 900 percent since the shutdowns. Given the extended isolation measures caused by the lockdowns, this is sad but unsurprising.
- Hospitals need revenue to keep operating. As an example, Ohio hospitals are expected to lose $1.2B a month. Hospitals shutting down would only put further strain on the health care system, which would be especially bad in the event of a second wave.
- In addition to the millions struggling financially, an estimated 12.7 million have lost their employer-sponsored health insurance.
- The tradeoff is not "lives versus the economy," but rather lives lost to COVID-19 versus lives lost trying to reduce COVID-19 deaths. Making decisions about lives saved versus lives lost is arduous, but it is not unprecedented. The question is whether our decision leads to a net-positive outcome.
- May 8, 2020 Addendum: A recently released study from mental health foundation Well Being Trust touches upon many of my previously made points regarding non-COVID health. The alarming finding this study is that 75,000 additional people could end up dying due to the suicides, alcohol abuse, and drug abuse caused by the unemployment, social isolation, and hopelessness caused by the lockdowns. If this study ends up being remotely accurate, it severely undermines the argument that the lockdown saves lives. Again, it is not about "lives versus economy." It is about the lives saved by the lockdown versus lives taken as a result of the lockdown.
- May 14, 2020 Addendum: The Lancet released a paper a couple of days ago estimating the effects of the lockdowns' disruption of food chains and health services in the next 6 months. The least severe scenario is 253,500 additional child deaths and 12,200 additional maternal deaths (Roberton et al., 2020).
- How much longer can lockdowns last, and can we voluntarily do social distancing? As human beings, we generally have a need for social interaction. As concerned as we are about the pandemic, quarantine fatigue is rearing its ugly head. Especially in a democratic society, you can keep people under lockdowns and stay-at-home orders for so long. Gallup polling from April 30 is showing that U.S. citizens are becoming less vigilant about social distancing. Location data from social networking service firm Foursquare shows that fast food and gas station visits are at pre-COVID levels in certain regions. Auto shops, big box stores, and convenience stores are seeing similar trends. Trails, hardware stores, and liquor stores are more frequently visited. Apple's mobility trend reporting shows that people are moving around more.
- Last month, I wrote on whether we can voluntarily social distance. Between the data I found then and the data from Foursquare and Apple, there is a clear trend that considerable social distancing was taking place prior to the lockdowns. This voluntary behavior that predated the lockdowns would limit the effects of the lockdown, and any subsequent study trying to measure the effects of the lockdowns would need to account for this voluntary behavior.
- The data are showing quarantine fatigue and less vigilant social distancing. As I will elaborate upon in the end, perhaps we need a different approach to deal with the inevitability that social distancing is going to become more lax, regardless of whether there is a government mandate. The question is whether we can minimize the severity of the social distancing while still addressing the public health concerns.
- COVID-19 doesn't affect everyone equally. According to a study at the Lancet, about 1 percent of those aged 30 or under will have severe symptoms (Verity at al, 2020). COVID-19 has a disproportionate effect on the elderly, as well as those with a pre-existing condition. While this does not provide comfort for those in either of those categories, this does have public policy implications because there is a clearly defined population at risk. Instead of requiring everyone to stay at home, state governments could implement an approach more targeted towards those vulnerable groups.
- Another point to be made is that not all states and jurisdictions are equally affected. New York state accounts for 33.1 percent of COVID-19 deaths, although its 19.5 million citizens account for 5.9 percent of the U.S. population. What is taking place in New York is not reflective of the rest of the country. This is why each governor should craft a recovery plan that takes into account the reality of COVID-19 within their state.
- There is not a guarantee of a vaccine. While a vaccine is certainly possible, anyone banking on the hope of one is optimistic, dare I say bordering on pollyannish. It is unrealistic to bank on a vaccine, least of all because having a vaccine in 12 to 18 months would be an optimistic timeframe. This assumes that we end up finding a vaccine. We have not found vaccines for other such coronaviruses as SARS and MERS. We have been looking for an HIV vaccine for 40 years, and guess what? Still nothing. It took a decade to find a vaccine for the deadly avian flu H5N1. We still haven't even found a cure for the common cold! While vaccines can provide considerable protection, they do not offer complete protection. The CDC recently found that the current flu vaccine is 45 percent effective. We have learned how to deal with other deadly diseases without a vaccine. While a vaccine would certainly help, we should also prepare ourselves for living our lives without the existence of a vaccine. As such, a vaccine should not be a precondition for lifting the lockdowns.
- Large-scale contact tracing might prove infeasible. There are Fourth Amendment considerations with potential violations to privacy for contract tracing, particularly if it is not voluntary. If it passes the constitutional hurdle, the public may or may not support it. Kaiser Family Foundation survey data suggest that support for contact tracing depends on implementation and addressing privacy concerns. As the Left-leaning Center for American Progress points out, there are the logistic challenges of implementing contact tracing in such a large country: adequate contract tracing personnel, only traces person-to-person contact (as opposed to contact with surfaces), a decentralized health system, a minimum of 60 percent cooperation rate, and other technical and procurement issues.
- Simply because a lockdown could be rendered safe does not make it wise policy. If we were only concerned with safety, we would have some weird outcomes, both in terms of public policy and our individual behaviors. Automobiles would need to be banned because over 30,000 people in the United States die from motor vehicle crashes (see NHSTA data here). 650,000 people die from heart disease. Exercise reduces the likelihood of heart disease, yet we don't mandate a daily exercise regimen for every U.S. citizen. About 5,000 people in the U.S. die from choking on food, but we are not going to mandate puréed food. By choosing to eat fatty and/or salty foods, smoke, or not exercise, people trade years of their life with less-than-healthy lifestyle choices because of their own perception of risk. This is not a call to throw all precaution in the wind or to say that we should not take any safety precautions (more on that below).
- What I am getting at is the following. First, death is an inevitable part of life. There have been over 200,000 COVID-19 deaths globally [as of 7:57am on 5/5], but there have also been about 20.19 million deaths total this year. COVID-19 deaths have accounted for about 1.2 percent of all deaths this year so far. Second, if we did not tolerate at least some risk, we would not live our lives.
- Epidemiological expertise in a pandemic is significant, but it is not to be the ultimate arbitrator in how we live. This expertise has to compete with other considerations and trade-offs, and it has to convince us of the severity of COVID-19, which brings me to my next point...
- Burden of proof is on governments to justify lockdowns, especially now. In the initial onset, a strong case could be made for a near-term lockdown as a safety precaution. We could not have known in February or even March if COVID-19 would end up as deadly as SARS, MERS, or the many other lethal diseases that have existed. If it were that deadly and we did not exercise caution, the death toll could have been staggering. The thing is that we're past the point of "better safe than sorry." The outbreak was not nearly as grim or dire as many early models suggested. In the meantime, the economy and the livelihoods of millions are taking a big hit. More COVID-19 data is being collected and disseminated, which means we can better project what is going to happen. Especially in a relatively free society that values "presumption of innocence," the burden of proof lies upon the governments to provide such measures are necessary or that there are not more moderate measures that could help. Until governors can use data and accurate models to back up their positions, their lockdowns are unjustifiable and should be gradually lifted.
- Are lockdowns an evidence-based practice? If you are going to deprive people of civil liberties, shut down large swathes of the economy, and try to delay the spread of COVID-19, we should ask whether there is at least some basis showing that it is a winning strategy. Lockdowns are a novel policy response. St. Louis had the most severe non-pharmaceutical interventions (NPI) during the Spanish flu pandemic, but none of those NPIs were lockdowns (Hatchett et al., 2007). During the Spanish Flu, St. Louis did not have a stay-at-home order, nor did it have a business closure that exceeded 48 hours. There was a very limited lockdown during the Ebola crisis, but nothing empirically definitive from that experience. Aside from that, we would need to use data from the current pandemic to prove or disprove its efficacy. There are two sub-questions that could be asked here.
- Do lockdowns slow the rate of transmission? A study on COVID-19 in Italy estimated that the lockdowns reduced transmission by about 45 percent, thereby averting 200,000 hospitalizations (Gatto et al., 2020). Going back to Point 3, the main goal of flattening the curve is to slow the rate of transmission. In the Gatto et al. study, the rate of transmission was still above 1.0, which means that the disease would not die on its own. At the same time, Italy's health care system was overwhelmed. If accurate, this study could be enough to justify a lockdown in an Italian context. However, since most places in the U.S. never exceeded capacity, I could easily argue that the lockdowns were or continue to be unjustifiable in the U.S., especially since University of Washington modeling shows that most states have passed their peak.
- Do lockdowns reduce the rate of deaths? I am more skeptical about lockdowns preventing deaths than I am in lockdowns reducing the transmission rate. Flattening the curve would, at best, have a minimal effect and would be contingent upon exceeding hospital capacity (See Point 3). In its analysis on lockdowns, the American Enterprise Institute (AEI) did not find correlation between lockdowns and change in daily deaths from all causes on a given date in 2020 versus a year earlier. AEI thus concludes that there is a lack of evidence for lockdowns for death prevention, and that other public health measures are more effective.
- May 7, 2020 Addendum: Economists from the University of California-Davis found that "non-pharmaceutical interventions [i.e., stay-at-home and social distancing orders] may have been effective in slowing the growth rate of confirmed cases of COVID-19, but not in decreasing the growth rate of cumulative mortality"(Lin and Meissner, 2020, p. 2).
- Side observation: I found a meta-study on the NIH website covering physical interventions for respiratory diseases. Across the 67 studies, it was found that a) hand-washing and wearing surgical or N95 masks were the most effective physical intervention reducing the spread of a respiratory infection, and b) there is limited evidence for social distancing (Jefferson et al., 2011).
The video above is an interview with Johan Giesecke, who is a senior epidemiologist who is a former advisor to the Director-General of the WHO.
As we receive more data, we see that COVID-19 is nowhere near as lethal as initially projected. All the while, economic damage has predictably been gargantuan. What makes that scarier is that we have not begin to see the damage and unintended consequences that the lockdowns have caused, whether to the economy, individual health, civil liberties, or the social unrest it will end up causing. Panic needs to replaced with data-informed decisions. While COVID-19 is serious, it is also true that fear has been misleading the public in terms of creating a proportionate response.
What does that response entail? I brought up a few ideas last month, but increasing testing capacity to isolate hotspots is vital. Expanding medical capacity would also help. In terms of gradually opening the economy, we should go beyond thinking in terms of "essential" and "non-essential" jobs. We should also think of it in terms of level of risk and use standard risk management to think of it in terms of "low, medium, and high risk." Laws requiring masks in public indoor venues, capacity limits in restaurants and bars, and a recommendation for keeping a distance of six feet also seem like good ideas. There are policy options that exist between "lock everything down" and "do nothing." States are starting to realize that. Such states as Texas, Florida, and Georgia have started with a partial reopening. Even the Governor of New York, which was the most heavily hit state, realizes that lockdowns are not an indefinite solution, which is why he released a recovery plan earlier this week. Now is the time to start implementing those policy alternatives so we can minimize both the public health and economic effects.
For more insight from health experts on the ineffectiveness of lockdowns, you can look at the analyses of Johan Giekse (former Chief Scientist at the European Center for Disease Control and advisor to the Director-General at the WHO), John Ioannidis (Professor of Medicine at Stanford University), John Lee (former Professor of Pathology at Hull York Medical School), Martin Kulldorf (Professor at Harvard Medical School), Michael Levitt (Nobel Prize-winning Professor of Structural Biology at Stanford) and Knut Wittkowski (Former Biostatistician at Rockefeller University).
Labels:
COVID Pandemic,
Economy,
Healthcare,
Lockdowns,
Vaccines
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