On the Disease and Lockdown Cure

A crisis of unprecedented proportions is upon us. In the last few weeks, suggestions from experts and requests from governments have been unsuccessful in convincing everyone to take all possible precautions. With ill-considered risky actions by many making it infeasible to rely on individual decision making, governments across the world have imposed very stringent restrictions. The consequent impact on the economy has been very severe. Business is suffering, many millions have lost their jobs and by all accounts, many more will. In India, nowhere has the impact of the lockdown been more apparent and more poignant than in the pictures of unemployed migrant workers walking hundreds of kilometers to get home. 

The US President has already called out the possibility of the effect of the lockdown being worse than the disease it is meant to address. Bolsanaro of Brazil has gone even further, stating that a few will die, but most will be unaffected by the virus. The leaders of many other countries though, including India, have acknowledged the economic distress, but have taken the position that the cost of not having a lockdown is too high. Besides creating a unique situation in which the critics of the Indian PM might have the US President in their corner, the immediate consequences of the lockdown across countries have raised the question: if a lockdown was the best response to the pandemic. 

Some have argued that maybe it would be better to let the virus claim its victims, fight the war in the hospitals as best we can and let other aspects of life be. This more extreme opposition harks back to UK's stated policy until a few weeks ago. Some others, particularly in India, have argued against the way in which the lockdown was implemented, positing that the government should have given people more warning. This, the claim goes, would have potentially avoided the problems that migrant labor is facing. These are both legitimate concerns. The debate around the questions that they raise will determine the decisions that governments will take, and these decisions will continue to affect our lives long after the passing of the pandemic itself. It is therefore imperative that we address both these suggestions as carefully as possible.

Counterfactual 1: cure worse than the disease 

If the case casualty rate (deaths/no. of confirmed cases) seems to be around a relatively low 4%, is it worth taking destroying the lives of so many; pushing many into poverty and starvation? A recession also claims lives, and particularly in the case of poorer countries, the toll can be severe and long-lasting. In order to determine if the lockdown is indeed a better policy than no lockdown for the situation we find ourselves in, we need to evaluate the counterfactual. A caveat that must accompany any such evaluation is that we will have to rely on many assumptions and there is no way to know with certainty 'what could have been'. And the uncertainty will increase as the days pass by, making it even more difficult to hazard a guess about what could have been if there was no lockdown. 

Most of the detractors of the lockdown also concede that even without a lockdown it would not have been business as usual. But point out that with the widespread acceptance of some reasonable form of social distancing, the effect of covid19 is not likely to be much worse than a very bad flu season. This implies that hospitals will get a large number of people coming in, but only a small proportion of them will die. In this scenario, even though the number of dead will be quite high, a countrywide lockdown might seem a little excessive given the costs that it imposes. Statistics on the effect of flu from the CDC provide some perspective and lend some credence to this view: each year, in the United States, on average 36,000 people die from flu-related complications and more than 200,000 people are hospitalized from flu-related causes. Even in the 2009 swine flu epidemic which led to almost 60 million infections in the US alone, only 12000 died, and there was no lockdown. Consequently, the economy which was already under tremendous strain did not suffer any significant adverse effects due to the epidemic. 

In order to get a more reasonable estimate of how things would have played out without a lockdown, it is pertinent to check if the numbers underlying this proposition stand up to scrutiny: 

1) Even if we take the proposed 4% as the true case casualty rate, small proportions do not mean small numbers. If the size of the infected population is large enough, the number of people requiring urgent medical attention will be very large. Therefore, the only way to reduce the number of patients requiring urgent care seems to be to reduce the possibility of getting infected. 

2) The comparison of the current outbreak to a very bad flu season misses out a key detail. This virus is not replacing the flu, it is going to supplement it. Increasing the numbers even further. The Swine flu data isn't particularly useful either, as effective antiviral drugs were made available early on leading to far fewer serious cases. 

The possibility of affected patients overwhelming hospitals is a nightmare scenario for a country like India. However, some of the consternation in India, particularly in the light of the migrant labor crisis seems to be driven by a low number and low growth rate of the confirmed infections relative to countries suffering the worst of the pandemic. This needs to be put in the context of the rate of testing. As of 27th March, India has conducted only about 19 tests per million people, one of the lowest in the world and very likely the reason behind low confirmed infections. The US provides a prominent example of numbers rising with numbers of tests. This should be of particular concern to a country like India, which already has a very high disease burden along with a weak public health infrastructure. The state of Jharkhand, for instance, has 1 doctor every 8700 people. Increased demand on this structure by a rapid surge in numbers of Covid19 patients will lead to high mortality from other diseases which will not get the required treatment. This will be made infinitely worse if health care workers get affected, reducing the size of the already small pool of medical professionals available to treat any disease, not just covid19. In all of this, the worst affected will be the people with low access to high-quality health care. 

These are not new arguments, they have formed the core of the recommendation to flatten the curve. Less severe measures than lockdown were tried in many countries: people were asked to maintain social distance, avoid non-essential travel and self isolate in case of recent international travel or if there were any symptoms. The results were not encouraging. Most of the countries that tried the milder measures in the early days swiftly moved to curtail individual choice. The possibility of huge externalities, with the action of one affecting many others and on the evidence of the indiscretions of many people, the only way to stem to tide seemed to severely restrict movement. 

It stands to reason that if the only way that the virus spreads is by people being in close contact, then fewer people being in close contact should slow it down. Yet the numbers of confirmed infections continue to grow. This also implies that in the absence of stringent measures, the virus would have spread even more rapidly. Now, to expect that the economy would have continued to function as it always has in the face of rising infections and possibly deaths is to presume that people have no regard for personal safety. While a few deviants can compromise a large society to the virus, we would need many, many more to keep the wheels of economy running at anywhere close to normal. 

An Indian media house recently framed the debate as one between lives and livelihoods, this seems to suggest that the choice is between an economic recession and saving lives. However, if there are no lives, there are can be no livelihoods, if lives are lost, livelihoods will eventually be lost, one way or another. The counterfactual to a lockdown, on the basis of the evidence we have coming in from Italy, Spain and other worst-affected countries, seems to be an economy which might have trudged on for a few weeks before collapsing to a position very close to one it is likely to be in right now, with all its concomitant effects. The economic impact of this non-lockdown slowdown will still be disproportionately high for the underprivileged, with a body count that will likely be much higher. 

Counterfactual 2: cure should have been better administered

Pictures of hundreds of thousands of migrant workers from across India have led many to question the urgency with which the shutdown and the subsequent curfew measures were imposed. How is it that despite having had the information for many weeks, the central government went from requesting a self-imposed 'people's curfew' to full lockdown in a matter of 3 days. If the process was more spread out, people were given prior warning we would not have the situation that we face today.  Migrants would have made arrangements to either travel to their native states or have explored ways and means of surviving where they were residing. 

The urgency of the move, whether stemming from incompetence or other more sinister motives, seems particularly baffling as India did not really have an obvious Wuhan like epicenter of the infection that needed to be insulated from the rest of the country. Further, if so many are in standing and cheek by jowl, did the outcome not beat the purpose of the lockdown. Both of these propositions require careful consideration, particularly because this tragedy is playing out as we speak while the threat of the Coronavirus is still in the future. And if the lockdown is going to be longer than currently stated, similar questions will arise again, very soon. 

In order to evaluate these concerns, let us consider a counterfactual in which the shutdown on March 22nd would have been announced 7 days in advance on March 15th. The news would have taken time to trickle down, but in a few days, it is likely that buses and trains would be bursting at their seams. If the mass exodus of migrant labor to (mostly) eastern states around the festivals Diwali/Chhath is anything to go by, 7 days would be inadequate. But these are extraordinary times and maybe arrangements could be made for additional trains and buses to take people to their destination of choice. In this best-case scenario, maybe we would not have had the current crisis. However, even this is not without serious problems:

1) The most obvious problem is the rush in the trains and buses would also provide fertile grounds for the spread of the virus. This seems to suggest that a mere preponement would not have addressed the problem of large numbers of people being in very close contact. In fact, it is possible that in this scenario more people would have chosen to return 'home' due to trains and buses being available. At the moment, it is quite likely that only the most desperate are taking the perilous route home

2) While it is true that India does not have a Wuhan like epicenter, the virus was imported into the country via people returning from other countries. International travel is limited to certain sections of Indian society and is likely to be highly concentrated in large cities or certain prosperous states. Most of the internal migrants would be traveling from these very prosperous parts of the country to poorer parts with weaker health infrastructure. If it is going to be tough for Maharashtra to deal with the surge of Covid cases, it is going to be almost impossible for Bihar. Facilitating travel to the hinterland would spread the infection to the poorest parts of the country and with more people traveling the spread would be faster. 

3) In times of rapid change, it would be unreasonable to expect that all information would be available to all decision-makers. It is very likely that many who did not choose to travel in the 7 day moratorium period will subsequently change their minds. Driven either by the continual decrease in economic activity or simply by the desire to be home, around near and dear ones in this time of great danger. 

This alternative scenario does not seem to be leading to outcomes that are any better than the one that is currently playing out. Further, the economic impact of the lockdown would not be any less severe in the counterfactual than it currently is. The sight of people cramming into trains might not be as heart-rending as the visual of people walking across state boundaries, but it is not clear that prior intimation of the lockdown would have alleviated the problems we face today. In fact, it might have made things worse. The option to call off the lockdown or to not have had one in the first place would have also likely disproportionately affected the people that are currently suffering the most. 

What now? 

While historical hypotheticals are useful in guiding future policy decisions, and there will be a time very soon when these questions will have to be asked again. But very rarely can the clock be turned back and insights gained be used to address the problem at hand. What might still help address the current problem, if the argument in favor of lockdown is persuasive enough, is setting up temporary camps with provisions of food and water and more importantly, testing. Once it is established that the person carries no risk, arrangements for travel can be made via trains to the capitals of their respective states. These arrangements must be made by the central government to avoid any inter-state haggling. Once in their state capitals, state governments can make arrangements for people to get back home. 

The hurried decision on behalf of some state governments to arrange for buses without adequate measure to test the ones traveling might come back to haunt the government. But it is not without cause, for most of us the pictures and videos are heartbreaking, for elected politicians they can be career-ending. In fact, as the crisis unfolds, the central government seems to be withdrawing many of its initial curbs. Apart from the lack of administrative capacity, it is tough to understand this worst of both worlds approach: we suffer the worst of the lockdown, as the virus continues to spread and will eventually bring more hardships, economic and otherwise. An oft-repeated statement is recent times is that in the fight against Coronavirus, a society is only as strong as its weakest link. The way forward is to strengthen the weakest link and try as best we can to fortify them against starvation and the risk of being infected.     

A friend recently pointed out that societies tend to pass down stories of past calamities to make sure that the next generation is prepared. In government, that institutional memory is codified in the idiom; look back, move forward. In the face of any abnormal circumstances, find previous instances of similar problems and draw on the experience of people who lived through times. In the present crisis, I believe our collective societal memory has failed us. Governments and citizens alike are ill-equipped and ill-prepared to deal with this crisis. In times like these, it is best to remember that there no good outcomes, only bad and very bad ones. Winston Churchill, after leading the UK to victory in WWII, lost the subsequent election. In this global war against an unseen enemy, the leader who leads their people to victory may not end up being the most popular one, history though, will remember.    

Thoughts and Predictions from March 18th, 2020

On Decision Making in a Global Pandemic

Until January 2020, anthropogenic climate change was the most clear and present danger facing human civilization. We were told we had to act soon and we had to act collectively to avoid the worst effects of increasing global temperatures, and by all accounts, we still have to. All the concerns around decision making at different levels, from individual to inter-governmental, that have fuelled the climate change debate have been brought into sharper focus by the unfolding Corona Virus pandemic. The questions are similar, but the timeline is much more compressed. 

What you or your government does or does not do today has an impact today, not 25 years into the future. Predictions can be substantiated or be shown to be worthless in a matter of days. And the decisions which rely on and simultaneously impact these predictions have to be made in an environment that is constantly evolving. Uncertainty abounds and the need to establish paradigms of sound decision making has scarcely ever been as urgent as it is today. This makes it imperative to revisit the basic, time tested principles of incentives and tradeoffs that underlie the choices we make. 

Context

As recently as a week ago, Coronavirus seemed a distant concern that only paranoid bothered with. 

In fact, on the 18th of March, I had received an email from an American colleague with the subject line: "While the world panics, India seems to be doing just fine. Yes?". And it did indeed look like we were doing fine. The confirmed case numbers were very low, governments had not taken any directed measures and while the university I work at had suspended classes, there was more of a holiday mood all around. But to anyone looking at the numbers more carefully, the prognosis was not very bright. I had responded to my colleague's question with a doom and gloom prediction (which I do not think it would be wise to share at this point in time) half hoping for some directives from the government. 

On 20th March we got the first clear sign of government action. The Prime Minister asked all Indians to observe a 'people's curfew' on 22nd March from 0700 hrs to 2100 hrs. He also asked everyone to engage in a collective show of solidarity with the women and men at the frontline of the crisis by clapping or clanging plates for 5 mins at 1700 hrs. Many praised the PM's initiative to unite the country and rekindle the spirit of lending a hand like the wars of 65 and 71. Many others lamented the gesture as a case of too little, too late, with particular consternation at the over-enthusiastic groups of people who took their show of solidarity to the streets or worse, celebrated their contribution to the nation's cause by having a post-curfew party. 

On the day of the people's curfew, many state governments announced lockdowns, taking many by surprise. Since then a nation-wide 21 days curfew has been declared and the government machinery which until then seemed intent on avoiding panic sprung into action. Though it still seemed incapable of grasping the magnitude of the challenge before them, possibly handicapped by the old dictum of the British system of bureaucracy: lots of things should be done, but nothing should be done for the first time.   

Individual's decision problem

As a species that evolved to survive the African savanna, we tend to seek comfort in groups. This instinct serves us well in times of danger. But congregating in groups is exactly what we have been asked no to do in order to limit the spread of the virus. So before we get into the nitty-gritty of the tough decisions that individuals have to make it is important to concede that the present crisis challenges ingrained habits and the road ahead is going to be very difficult. 

The WHO guidelines on what is expected of individuals are pretty clear, however, they are not straightforward to adhere to. For instance, it is almost impossible to not touch your face or keep away from surfaces that might have been touched by others. Hence, we had more the more severe, but easier to implement measure of quarantining people. The severity of the quarantine was sequentially increased from being initially restricted to high-risk cases to a generalized lockdown. The increase in severity of the measures has at least partly driven by the inability or unwillingness of individuals to adhere by the less severe ones.    

Why is it that even in the face of a demonstrable threat, people have not taken adequate precautions: violated quarantine, traveled long-distance, even partied? The choice boils down to the individual perception of the opportunity cost of being locked indoors. For instance, if none of my friends have to go to the office, more people can join my party, increasing its payoff and consequently increasing the opportunity cost of maintaining quarantine. On the other hand, the opportunity cost of partying is the increase in the probability of the individual getting infected with a deadly virus due to attending a party. But before we pontificate on the obviousness of choosing to avoid a party in these times, consider that on average 10 people die every day on the railway tracks of Mumbai's suburban railway. Our subjective perception is not very well tuned into evaluating the probability of our own mortality, leading to many flawed decisions. We will revisit this problem of errors in estimation in the next section. 

   

Further, it is obvious that the impact of the decisions made by individuals is not limited to the decision-makers. If a person had increased their risk of infection, they have joined the chain of infection, becoming a potential vector that increases the probability of others being infected. This (negative) externality whereby the choices of an individual affect others; complicates decision even more as the social cost of an action, say organizing a party, is much higher than its personal cost. The standard prediction of an introduction to economics course in such a scenario would be that people will over-engage in such activities. Climate activists have been pointing out a similar problem, where individuals consume more fossil fuel than is socially optimal as the cost they pay individually does not reflect the cost their decision imposes on the entire society.  

So, the deck is stacked against us (1) we need to do things that go against our basic instincts (2) we seem to have limited ability to gauge the cost of an activity in terms of probability of mortality (3) even if we can take our own mortality into consideration, our decisions impose costs on society that are difficult to estimate. It is for these reasons that governments across the world, given the urgency of the situation have now started introducing the extraneous cost of fines and/or punishment to get people to comply. From the UK to Germany to India, law enforcement agencies are being empowered to make sure that people comply with lockdowns. We have forfeited our freedom to make independent decisions and in the process demonstrated our inability to deal with immediate and urgent threats as individuals. 

The way forward

France has its army policing the streets of Paris and this might very soon be a reality for the big cities in India. But while their presence will be deterrent, it will not completely eliminate the possibility of individuals violating the lockdown. They are not omnipresent and there will be opportunities that can be exploited by sufficient motivated individuals: those for whom the opportunity cost of social isolation is very high. 

Now, particularly in a poor country like India, there is going to be a very large group of daily wage earners for whom the cost of a lockdown is going to be very extreme. As we get deeper into the lockdown, even people with monetary resources will start running out of food. The arrangements that governments are making might help some, but if the initial reports are anything to go by, there is insufficient state capacity to provide food materials to millions of people. If the lockdown extends for any longer than the current 21 days, well, we might be getting too ahead of ourselves with that hypothetical. But if the choice is between increasing the probability of getting infected and starvation, it is not too difficult to imagine what even the most level headed amongst us would choose to do.  

For now, it is imperative to recognize the failings in decision making that led us to this situation and make amends, to the extent that we can. Our estimations of incentives and tradeoffs depend on the assumptions we about the repercussions of a decision, so it is relevant to identify the ways in which they can go wrong. Consider the following situation: person A is in a cave, A's decision to leave the case depends on whether there is a tiger outside the cave. There are two possible kinds of errors that A can make: (1) assume that there is a tiger outside the cave when there isn't one (2) assume that there is no tiger when there is one. A reasonable argument can be made that error (2) is far more dangerous.  And therefore it is very likely that we evolved to avoid making the (2) type of error, erring more on the side of being cautious than cavalier. While that may be true of the species generally, in our tendency to commit (2) errors, we are likely distributed over a spectrum ranging from extreme paranoia to extreme risk-taking. This is why even under normal everyday circumstances we observe a disparate range of responses to the same situation. The same tendency that makes someone a risk-taking entrepreneur, also makes them take more risky decisions in times like these. 

In addition to the extreme risk-takers, there is also the fact that modern civilization has created an environment in which (2) type errors are not as risky as they would have been in times gone by. This is not a critique the advances that we have made in modern medicine, engineering, and governance structures, it is merely to point out that by reducing the cost of errors we have made people more likely to make errors even in times when the cost is likely to be very high. And while this is more true in the richer countries, the well off in the global south has not been immune to these changes. In the last few days, there were exhortations by the ones in the know to their near and dear ones to buy basic food items. But in times of Amazon pantry and Bigbasket, it is so difficult for people to imagine food shortages, that many ignored the advice, only to find themselves in a perilous situation with the implementation of the lockdown. It seems that paradoxically, the progress of human civilization might have created an environment that endangered its further progress. 

How do we address this? Possibly the best way forward is to at least in the current scenario: (a) try to consciously move toward the paranoid end of the scale (b) try to maximize considerations of social costs of your actions by thinking of people around you who your actions might immediately impact. Listen to interviews of experts who have been shouting their lungs out for the last 2 months (an example: https://www.youtube.com/watch?v=dcJDpV-igjs). With the proliferation of the internet, there seems to have been a growing distaste for experts, people who have dedicated many years to understanding and addressing a particular problem. Now may not be the best time to undermine the importance and relevance of knowledge accumulated by the experts. Listen to the stories coming in from Italy and Spain imploring the rest of the world to not make the kind of mistake they made. 

Can the experts be wrong? Of course, the increasing temperatures might yet drive the virus away or maybe the threat was overstated. While no one can guarantee with absolute certainty that the experts have not committed an error of type (1): they have said there is a tiger, when there isn't. And if that is the case, we will find out soon enough. But, if they are right and we commit an error of type (2), the consequences might be too catastrophic to consider. 

Stay at home, stay safe.