The Risks of Action and Inaction

I agree with Allison Schrager’s assessment from her op-ed in the Wall Street Journal:

Almost everything about the novel coronavirus is uncertain. It was unexpected, though perhaps more of a surprise than it should have been. Public-health experts have been warning for years that a pandemic could happen. But every few years come warnings of potential catastrophes that never seem to materialize.

Among the unknowns about the virus: the true hospitalization and death rates; how infectious it is; how many asymptomatic patients are walking around; how it affects young people; how risk factors vary among different countries with different populations, pollution levels and urban densities. It seems certain the virus will overwhelm hospitals in some places, as it has in China and Italy. We also don’t know how long these extreme economic and social disruptions will last. Without reliable information, predictions are based on incomplete data and heroic assumptions.

This uncertainty makes it much harder to manage the virus, or to strike a balance between public health and the economy. What happened in 1918 or 1957 isn’t particularly instructive. The virus is different. The world is different. So is our health-care system.

The goal should be to move from uncertainty to risk, which will take time and data. The way forward is testing as many people as possible—not only people with symptoms. Some carriers are asymptomatic. California is starting to test asymptomatic young people to learn more about transmission and infection rates. Testing everyone may not be feasible, but regularly testing a random sample of the population would be informative.

This helped in South Korea, which tested thousands of people a day. South Korea has managed to slow the rate of new cases and gather data about how the disease has spread, its effects on different populations, and the mortality rate in that country. More testing would also help spare the world from future shutdowns if the virus reappears before there is a safe, effective vaccine.

Every medical test has some rate of false positives and negatives. The error rate for Covid-19 tests may be especially high. Scientists are still learning about how long the virus lives in the body. Administering tests takes skill and is prone to human error. We don’t know how reliable tests were in China; studies suggest the false-negative rate there is between 3% and 50%—an enormous range. If tests aren’t reliable, the supposed source of certainty can create even more uncertainty. The Food and Drug Administration must balance the urgency for more testing with caution to ensure new tests meet its standards for accuracy.

Policy makers should throw as much energy as possible into getting accurate data. That would allow the world to assess the real risk of the coronavirus. This may lead us to continue to take drastic action to limit its spread, or it may allow us to temper our response, managing the risk at a much lower cost to both society and the economy. Whatever the response, it will be appropriate, based on an assessment of risk—not uncertainty and fear.

What is needed is not just diagnostic testing but epidemiological testing. Right now I believe that most elected officials are acting from political calculus or just plain panic rather than responding to COVID-19. I’m not sure how else you can explain that Illinois is “locked down” (population 12 million/1,200 COVID-19 cases) while Washington State (population 7 million/2,200 COVID-19 cases) is not.

17 comments… add one
  • steve Link

    (Waiting for yet another meeting.) You could be correct, but just a cautionary word. There is a lot unknown and a lot of real disagreement about what to do. Some of the decisions are being made heavily based upon resources not necessarily what would be done in ideal conditions. Making fun of politicians is one of our national sports, and I am sure it is influencing decisions, but some of this will not be easy and will not have clear cut answers.


  • CuriousOnlooker Link

    Washington state declared a lockdown yesterday

  • steve Link

    “Policy makers should throw as much energy as possible into getting accurate data.”

    Kind of blew that already with inability to test, but as they become available, we are getting more but still not enough and tests can still take up to 5 days, we can at least track the disease once it is established.


  • Guarneri Link

    Collecting data, stockpiling resources etc should have been started 20 years ago. The swine flu surely should have been a wake-up call. But we are not good at that.

    A key sentence was “…moving from unknown to risk…” That’s the whole thing. Trade-off in an unknown environment is guessing. In a risk assessment environment its called life.

    Separately, the Stanford – U Alabama report cast the use of malaria drugs or cocktails in a more positive light than do media reports.

  • steve Link

    “But Rigano is not a doctor. Nor is he affiliated with Stanford’s medical school — it is actively trying to get him to stop saying he is an adviser. And his claims about chloroquine are unproven, often overstated and potentially harmful.

    Rigano and his associate James Todaro have rapidly gained attention for their paper on chloroquine, self-published on Google Docs, which they claim to have written “in consultation with Stanford University School of Medicine, UAB School of Medicine and National Academy of Sciences researchers.”

    Stanford University School of Medicine and the University of Alabama, Birmingham, School of Medicine told HuffPost that no one from their institutions was directly involved in Rigano and Todaro’s paper. The National Academy of Sciences was also not aware of any connection between Rigano or Todaro and the organization, according to a spokesperson. One UAB researcher requested that his name be removed from the paper after he was initially listed as an author and denied he had any knowledge of it or any part in its creation, he told Wired magazine in a Thursday profile of Rigano and Todaro.”

    “Rigano’s description of chloroquine’s effects is largely based on a single study from France that tested its use on a group of only 20 people. Six additional patients were also given the treatment but dropped out of the study before its completion: Three were transferred to intensive care, one died, one left the hospital and another stopped treatment because of nausea. ”

    Even the paper itself has a massive disclaimer in it trying to distance the authors from any liability and damages it may cause, and stating “the authors and or its affiliates does not guarantee the accuracy of or the conclusions reached in this white paper, and this white paper is provided ‘as is’.”

    Rigano’s LinkedIn profile lists him as “currently on leave” from a master’s program in bioinformatics at Johns Hopkins, while Todaro’s profile says he has a medical degree from Columbia University and is a “cryptocurrency investor and entrepreneur.”

    Just out of curiosity, which science or medical journals do you read?


  • I noticed that about the study. It’s terribly constructed.

    Now that doesn’t necessarily mean that chloroquine won’t be effective in treating COVID-19—it might. There just isn’t much evidence right now. IMO we’re at the point at which a lot of people are throwing things against the wall.

  • steve Link

    This is the kind of paper I like to use to teach medical students. It has lots of red flags. Neither has a real record of research, especially original research. Neither appears to be affiliated with a university. Not peer reviewed. Very small numbers of people in the study. (Is there anything you can “prove” with a small study? Finally, they guys are on TV a lot. For a small iffy study.

    Maybe they end up being correct, this study is not the one to suggest it.


  • Plus both chloroquine and hydroxychloroquine are not the sort of things one could prescribe casually at the doses that are being discussed, especially if they’re going to be taken for any substantial period of time. That needs to be monitored closely, especially to identify emerging eye problems.

  • PD Shaw Link

    Yeah, someone just died self-medicating with chloroquine.

    One unknowable that keeps coming up for me is the weather related stuff. IF the onset of warmth and humidity significantly reduces the rate of replication, then there is a certain efficiency from mandating social-distancing, etc. before any seasonal affects come into play. Razib Khan looked at the last pre-print edition about the summer effect, and observed that these are the months that the absolute humidity would be at necessary levels:

    Now: Miami
    April: Dallas; Houston
    May: Atlanta; Chicago; Washington DC
    June: Boston; Los Angeles; New York; Philadelphia
    July: Seattle
    Never: San Francisco

    This is not terribly promising theory for whether the onset is highest right now we’re still over thirty days from when any summer effect for the upper South and lower Midwest. But I do wonder if the medical system needs to prepare for moving people to areas with more room?

  • I don’t think the hypothesis is particularly convincing, particularly considering the large number of cases in Singapore. Note, too, that India (the entire country) just went into “shelter in place” mode.

  • Greyshambler Link

    I’m gonna go with the hair dryer in the nose.

  • PD Shaw Link

    I think India is responding to WHO and media sources that keep saying India is the next hotspot. Its poor and crowded, but only has less than half of the confirmed cases as Illinois.

  • It’s a big problem for my Indian colleagues. The electrical power supplying their homes tends to be iffy which makes working from home a lot harder.

  • steve Link

    One of our former med students is doing an ICU fellowship. He is staying in contact with me. He is from Columbia. Says they are taking it very seriously down there. They know they don’t have the medical system to handle Covid.


  • CuriousOnlooker Link

    The seasonal effect only works (if it works) if people turn off the AC.

    That would render work environments unsafe in most of the country.

  • There are places in the United States where a workplace without air conditioning would be unsafe (Phoenix, AZ for example). I grew up without air conditioning in St. Louis, Missouri, where the temperature and humidity are both around 100 between June 15 and September 15. Heat and humidity don’t really bother me.

    But there are a lot of people who’ve never experienced anything like that.

  • Andy Link

    “It’s a big problem for my Indian colleagues. The electrical power supplying their homes tends to be iffy which makes working from home a lot harder.”

    I don’t know the kind of firm you work for, but perhaps this will show management the limitations of foreign remote workers.

    “Collecting data, stockpiling resources, etc should have been started 20 years ago. The swine flu surely should have been a wake-up call. But we are not good at that.”

    I found out today we do have a stockpile. Problem is that it isn’t big enough for a pandemic. NY Governor Cuomo claims the strategic stockpile has 20k ventilators and he wants all of them for his state. Today Pence promised 4k of them. But no one has confirmed that 20k number and the FEMA director was on the TV over the weekend stating he has no idea how much of what is in the stockpile. That would seem to be important information for a FEMA director to know. Regardless of what the number is, I have no doubt that the stockpile will be insufficient to the need.

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