Why we need a national response

It seems quite clear now that we do not do a very good job of projecting COVID-19 progression. There are many reasons. One is that it is hard to predict how people and governments will behave. A fraction of the population will practice social distancing and withdraw from usual activity in the absence of any governmental mandates, another fraction will not do anything different no matter any official policy and the rest are in between. I for one get more scared of this thing the more I learn about it. Who knows what the long term consequences will be particularly for autoimmune diseases. The virus is triggering a massive immune response everywhere in the body and it could easily develop a memory response to your own cells in addition to the virus.

The virus also spreads in local clusters that may reach local saturation before infecting new clusters but the cross-cluster transmission events are low probability and hard to detect. The virus reached American shores in early January and maybe even earlier but most of those early events died out. This is because the transmission rate is highly varied. A mean reproduction number of 3 could mean everyone has R=3 or that most people transmit with R less than 1 while a small number (or events) transmit with very high R. (Nassim Nicholas Taleb has written copiously on the hazards of highly variable (fat tailed) distributions. For those with mathematical backgrounds, I highly recommend reading his technical volumes: The Technical Incerto. Even if you don’t believe most of what he says, you can still learn a lot.) Thus it is hard to predict when an event will start a local epidemic, although large gatherings of people (i.e. weddings, conventions, etc.) are a good place to start. Once the epidemic starts, it grows exponentially and then starts to saturate either by running out of people in the locality to infect or people changing their behavior or more likely both. Parts of New York may be above the herd immunity threshold now.

Thus at this point, I think we need to take a page out of Taleb’s book (like literally as my daughter would say), and don’t worry too much about forecasting. We can use it as a guide but we have enough information to know that most people are susceptible, about a third will be asymptomatic if infected (which doesn’t mean they won’t have long term consequences), about a fifth to a tenth will be counted as a case, and a few percent of those will die, which strongly depends on age and pre-existing conditions. We can wait around for a vaccine or herd immunity and in the process let many more people die, ( I don’t know how many but I do know that total number of deaths is a nondecreasing quantity), or we can act now everywhere to shut this down and impose a strict quarantine on anyone entering the country until they have been tested negative 3 times with a high specificity PCR test (and maybe 8 out of 17 times with a low specificity and sensitivity antigen test).

Acting now everywhere means, either 1) shutting everything down for at least two weeks. No Amazon or Grubhub or Doordash deliveries, no going to Costco and Walmart, not even going to the super market. It means paying everyone in the country without an income some substantial fraction of their salary. It means distributing two weeks supply of food to everyone. It means truly essential workers, like people keeping electricity going and hospital workers, live in a quarantine bubble hotel, like the NBA and NHL or 2) Testing everyone everyday who wants to leave their house and paying them to quarantine at home or in a hotel if they test positive. Both plans require national coordination and a lot of effort. The CARES act package has run out and we are heading for economic disaster while the pandemic rages on. As a recent president once said, “What have you got to lose?”

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