Bill Gates was right when he said that when historians write about this pandemic, the larger part of that text will be documenting the months and years after the initial outbreak.
While the curves appear to be flattening across most countries, the war is no where near considered won. We have endured a month or two of lockdown and already, people are talking about the exit strategy and what comes next.
I'd like to outline what I think is the appropriate path forward for the US and the world in the face of the coronavirus pandemic.
A brief summary of where we are.
This is the first blizzard of a long winter. We are going to be menaced by this virus for a long period of time, and it is going to kill a lot more people before this is over. There's no way around that.
Experts remain hopeful that hydroxychloroquine or another medication may work for prevention (pre or post exposure); right now the data suggests it is ineffective for treatment of severe disease. Remdesivir seems to have more promise, though that is far from confirmed. Convalescent plasma appears likewise to have a potential effect, far from confirmed. Ivermectin needs to be subjected to a clinical trial. There are other treatments under development. All this will take time, and until we have clinical trial proven therapies that can be deployed broadly, we will make only incremental gains in treating this disease as clinical familiarity with it increases. Breakthroughs are probably months away, if they come.
Social distancing policies have mostly served their purpose: to prevent hospitals from being overwhelmed, to preserve PPE, and delay some infections so that better outcomes can be had. Most of the country has managed to prevent situations of ICUs being over-run.
The economic devastation caused by the virus is mostly caused by the pandemic and the responses of individuals. State action worsens it, but is not wholly responsible for it. Rather, stat action probably creates a minor increase in economic damage. The reality is that most businesses that have been ordered closed would not be able to operate profitably if they were allowed to open, due to the individual choices of consumers. It is important to keep this in mind because if your goal is to facilitate economic well being, you should not be looking primarily towards the state. More on this below.
So, what should be done going forward?
A decentralised approach to non-pharmaceutical interventions needs to prevail: the policies that are right for New York City aren't right for Spokane, Washington nor are they right for Upstate New York. That is largely already understood, as Governors, not the Federal Government, have the authority over emergency declarations and orders.
Restrictive orders need to be pared back to address only the highest risk type of activities, mainly those that involve the gathering of large numbers of people. Large gatherings will probably not be possible or responsible for the next year, and represent a grave enough risk to public health that state intervention is justified.
It must be understood that economic costs are human costs, and that economic problems caused by the virus are going to be more modest, but still tremendous regardless of what the state does. We must figure out safe and responsible ways of conducting economic activity and production while mitigating the risk of contagion. This is something that the private sector is best equipped to do. Businesses need to innovate and figure out ways to operate profitably while observing the appropriate anti-contagion strategies, and the state should step in only when there is a level of carelessness that represents a significant threat to the public. Yes, this is messy and difficult and ambiguous and fraught with problems. Clearly, New York City cannot embark on this path at the same time as Sioux City, SD. It is, however, in my estimation, the best way to balance the need for economic production with the need to control the virus. Businesses need to figure out how to operate under the current conditions and the market needs to pick the winners and losers--with state intervention limited to cases where it is clear that a business is externalising the risks of their operation to the community.
Testing and contact tracing need to be dramatically increased. Nearly every county has a health department that has a system for tracing the contacts of those with contagious disease. In most places, that contact tracing system is overwhelmed. Many people will disagree with me on this point, but I think curbing contagious diseases is a core function of local government, and in general they do it rather well. Rather than focusing state resources on harassing people who take their kids to the park, it is far better to focus on augmenting the contact tracing capacity of county health departments, and continue to pare back regulations on testing manufacture and import to increase the number of available tests. This is an extremely valuable mitigation strategy, and is especially vital if we are to have a market driven process for determining which businesses can operate and under what conditions: the market needs high quality information about where people are getting infected. This creates the threat of bad publicity and a drop in revenue for businesses that fail to implement adequate mitigation strategies. Without a system that interviews people who've gotten infected, traces their contacts and compiles and publishes data, there is an inadequate incentive for businesses to engage in the proper mitigation strategies.
PPE production needs to dramatically increase, which means loosening restrictions on manufacturers, and permitting the rapid importation of these supplies or their components.
The role for medical research has never been more important. I have been so extremely impressed with the speed at which clinical trials have been designed and improved. We continue to require the freedom to make individualized medical choices, but equally important is obtaining definitive answers to clinical questions about the safety and efficacy of treatments with high quality clinical trials. As we learn more, we will get better at treating this disease.
People need to be understanding of the good intentions of others while the entire world has a spirited debate about the proper way forward. The angry rhetoric that is so common is unhelpful. Everyone involved wants to save lives, and sees their proposals as a way to do that. Debate is healthy, anger at people acting with good intentions is not. I've been guilty of getting angry too--and I must keep reminding myself that rational discourse must prevail in order to save the maximum number of lives.