The Second Curve: Questions and thoughts on the coronavirus pandemic: March 2020


Every day brings more jarring and complex questions about the global pandemic. We are not seeing improvement, except in China and South Korea. Western countries, supposedly so wealthy and powerful, seem incapable of dealing with the crises. There  may be some glimmers of hope. But all is not well.

As leaders grasp for quick solutions and tell publics all will be fine with lockdowns, they don’t communicate well the overall challenge, or what is expected in the long-term.

In my last post I noted some of the known unknowns and some questions that were raised by the expert study that many governments are relying on for theories about “flattening the curve.” I want to go go back to two key parts of theImperial College London study, the one that the UK and US read and made them change their views on March 11.

Aspect 1: Combining all four interventions (social distancing of the entire population, case isolation, household quarantine and school and university closure) is predicted to have the largest impact, short of a complete lockdown which additionally prevents people going to work.

Aspect 2 We therefore conclude that epidemic suppression is the only viable strategy at the current time. The social and economic effects of the measures which are needed to achieve this policy goal will be profound.

These two details raise important issues about the economic impact. Policymakers have bee trying to triage society in a battle of attrition with the virus, and they want to save their health systems. One needs to ask why the health systems are so fragile in the first place that cities like New York say they are short millions of items in the following weeks. One might wonder why China is shipping those items, despite having just recovered from the outbreak. The Imperial College study said the virus would return for up to 18 months despite “herd immunity” and that flattening the curve takes months. In China the virus appears to have been beaten between January and March 15.

The Chinese success raises some questions.

The WHO didn’t declare a pandemic until March 11. In retrospect that seems very irresponsible. It was already in Italy and South Korea. It has only been a week since then and the crises in the US and Europe has grown rapidly worse as deaths rise.

We now know that experts believe this could go on for 18 months.But countries have not prepared their citizens for that. I detailed some of my concerns in a recent piece at The Jerusalem Post. I’ve noted some basic problems in what we don’t know. “What we are left with is a series of complex questions. Egypt reportedly has only 206 cases of the virus and six deaths. Could a large country like that, without much testing, simply miss large numbers of cases? Iran, which suppressed information about the virus’s spread in February, claims it has 18,000 cases and 1,200 deaths. If countries lie about the number of deaths, or if they don’t test at all, what do we know? ”

I argued that “The elephant in the room at the end is the study never looked at the economic impact. It did note that after the initial suppression of the virus was enacted, interventions would be relaxed in September and infections would rise again. World leaders are not telling the public that this is what they face.”

The BBC is catching on to the economic problem. I call this:

The Second Curve

While the pandemic curve is flattened so that hospitals can still function, a second curve can have a terrible peak. That is the economic wasteland ahead. The BBC notes“It can take a long time for the tide to go out – possibly years. It is clear the current strategy of shutting down large parts of society is not sustainable in the long-term. The social and economic damage would be catastrophic. What countries need is an “exit strategy” – a way of lifting the restrictions and getting back to normal.”

A lot of countries are thinking aboutlaw and order and lockdowns first. For instance, “A man has been arrested for allegedly failing to self-isolate after arriving on the Isle of Man amid the coronavirus pandemic. The island has passed emergency legislation requiring new arrivals to quarantine themselves for 14 days.”

Governments want to spend their way out of the problem. “In the United States, the price tag for the government’s coronavirus response package is at $1 trillion-plus, a source estimated on Tuesday. In the UK, a £330 billion ($400 billion) plan was announced, and various badly hit countries in Europe have also unveiled 12-figure packages this week.”

But this eventually necessitates printing money. There is false hope when the US President says that this thing can be beaten in 15 days.

Let’s look at Israel, as a short case study. Israel banned people early on and then began rolling and increasing lockdowns on March 19. It uses anti-terror tech to fight the virus. Already 400,000 have registered for unemployment, around 6,000 register an hour.  700,000 or a million will register by the end of the month. The general refrain is that to question the current policy is to object to “epidemiologists.” This is not accurate though. Experts didn’t encourage total lock downs and they didn’t look at the economic cost. Israel had to act early because it doesn’t have enough ICU beds. So many countries put themselves in a vulnerable situation.

But what about much poorer countries? What about Egypt or India. There is lack of clarity why these countries do not see the kind of death toll of Italy. There are questions about why South Korea had a low death toll and why infections ceased in China. No new local infections, China says. Yet how did China manage to stop the spread from Wuhan when western countries couldn’t? Italy tried to quarantine the north and it didn’t work. Italy’s death toll has now surpassed China with 41,000 infect and 3,400 dead on March 20. China had 80,928 and 3,245 deaths on March 20. South Korea had only 91 deaths.

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We’ve heard that the main reason to flatten the curve is to prevent ICU’s being overrun. But South Korea’s experience shows you can have thousands of cases and very few are very serious. Yet France and Spain seem to be on an Italian journey with high rates of infections and death toll. Iran, which followed the “do nothing” model also has a high number of deaths, 1,200 officially on March 20. Switzerland looks more like South Korea, with 4,000 infections and 40 deaths. Also the UK and US seem to be doing better. Nevertheless the infections are rising.

Something that doesn’t make sense is that many cases appear to have been misdiagnosed as flu. Clay Bentley was sent home for instance, his conditions worsened and he returned. The CNN timeline appears to show he was sent home on March 2. Another man who appeared on CNN on March 19 also had a similar story of going twice to doctors who told him he had flu and then pneumonia. That has led some to question whether large numbers of people have been misdiagnosed. In the US the issue of testing was always on the main concerns. Hand-in-hand with people being labelled wrongly as having flu it is troubling. But if the model for the “do nothing” approach where hospitals are overwhelmed was correct then why didn’t the US see the surge at ICUs in February

Something doesn’t make sense. In countries that lack testing, such as Egypt, where media claim the numbers are higher than reported, should we see medical systems being overwhelmed the way the “curve” model predicts? Lack of testing is only one issue. If you test no one and do nothing the models say that health systems will be overwhelmed. It should have happened in some places, besides Italy, already.

This is what doesn’t make sense. New York Mayor Bill De Blasio has said “”New York City is buying! Our country is facing a drastic shortage and we need ventilators ASAP.” Reports note “New York state will be in desperate need of hospital beds and ventilators soon and may need more than 12 times the existing intensive-care capacity.”  According to reports as well: “ There are now more than 800 cases of the virus in New York City and a drastic shortage of healthcare officials and medical supplies.” This is a “dire shortage of masks in New York City.”The city also needs these supplies, many from China, which arrive on trucks. “Experts agreed that the health of the trucking workforce is critical to the functioning of the supply chain.” We know how we got here. The city warned in February about lack of masks. At the time it couldn’t do its own testing but had enough hospital beds.

According to a report China was able to beat the virus in Wuhan by acting earlier. “Less than 20% of the residents of Hubei Province, where the outbreak began, became infected, but that was because the Chinese government imposed strict social distancing very early.” China had begun major shutdowns on January 23. “Authorities in Wuhan shut down the city’s public transportation, including buses, trains, ferries, and the airport.” The quarantine spread to fifteen other cities on January 28 with some 50million locked down. On February 24 some Wuhan residents spoke out about what happened. They said they were first kept inside but then later sent to quarantine centers. “They couldn’t provide me with a hospital when I was sick. Now when I’m recovered, they forced me into one.”

In Italy the situation is so dire one nurse said they have stopped counting bodies.

China is now positioning itself to help other countries and its image has improved from the crises. China is portrayed more often as a victim of Trump’s term “Chinese virus” and has received applause for offers to help Italy and send ventilators and masks. This leads to questions about how they were able to recover so quickly.  They have kicked out some media in the process. How come China’s infections are now reported as zero? The WHO has praised China’s efforts. Could China’srole reshape world order, as one article argues. Is this a gamechanger or disruptor?

There was a US-China trade war before the pandemic. A phase one deal was agreed on December 13, 2019. It was signed on January 15. On Day 563 of the “war”: January 13, 2020 – US officially drops China’s currency manipulator label. US National DefenseStrategy unveiled in January 2018 also singled out China as a threat to be confronted. The US was also continuing to pressure the UK regarding use of Huaweiin January and March 2020.

China has showered Europe with coronavirus aid in the last weeks. Doctors and supplies arrived in Italy on March 19, showing China doesn’t need them urgently at home. Richard Haass praised China. “ standing taking a hit b/c of how badly we are handling #coronavirus at home & how little we’re doing for others. China, despite its being where the virus began & its dropping the ball at first, gaining influence b/c it is meeting the challenge at home & offering help to others.” Brett McGurk wrote “his is the sort of thing the United States once did through leadership and competent diplomacy. Now, as the CDC advises desperate American health workers to make their own masks (or use a “bandana”) China ships millions of masks and 50k test kits to American allies in Europe.” Ursula von der Leyen thanked China as well. 

It’s not the economy anymore stupid? There is a SECOND CURVE coming, the economic curve. When you flatten the pandemic curve, which may be a good policy, if you don’t try to flatten the economic curve you’ll be in trouble. The public health experts simply see one part of an elephant and are very good at knowing about that part. You can rely on the exact same expertise and study and come away with two different policies. Those who crafted models relating to the pandemic relied on sets of data, maybe incomplete or not, they gave a model, they gave it to policy makers to decide what next. The problem is that an economic model is not in place yet. 

We have some trajectories to look at.

China is one trajectory. Lockdowns began on January 23 and by March 19 there were no cases. That’s two months. The death toll was large, but less than Italy. Total control was used by the government and mass mobilization.

Italy began a lockdown on March 10 after putting 16 million in a lockdown in Lombardy on March 8. Italy has a large and growing death toll and infection rate. It has received support from China now.

South Korea lockdowns began around February 21. By March 13 museums and sites were re-opening. It began the lockdown in the southern cities of Daegu and Cheongdo which were declared “special care zones”. The streets of Daegu were mostly deserted by January 21. Well prepared from previous experience it seems South Korea has done well. It had 152 new infections on March 20 and 7 deaths.

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Data and details from the Science Magazine article. (see link)

It is worth readying about South Korea’s experience “Other countries have beat back the virus without such drastic measures. One example is South Korea, which has seen confirmed infections drop from 909 cases on 29 February to just 74 early this week. ‘South Korea is a democratic republic; we feel a lockdown is not a reasonable choice,’ says Kim Woo-Joo, an infectious disease specialist at Korea University. Instead, the key to success has been a large, well-organized testing program, combined with extensive efforts to isolate infected people and trace and quarantine their contacts. By 16 March, South Korea had tested more than 270,000 people, many at a network of dozens of drive-through testing stations, a strategy followed elsewhere that eases access to testing and prevents infected people from exposing others in waiting rooms.” South Korea’s economy was not affected by the virus, at least not much. “By industry, the health and social welfare sector added 202,000 jobs, and the transportation sector added 99,000 jobs amid rising demand for delivery services in the wake of the novel coronavirus outbreak.” It added jobs while western countries are watching their economies potentially collapse.

Meanwhile in Israel, despite tough measures, a further 28 cases were found Friday, March 20, bringing the total number to more than 700. However Israel had no deaths by that point.

Iran, it appears, did little to stop the spread besides closing schools in late February and then beginning some travel restrictions. Its death toll officially is less than Italy’s.

Focusing on the second curve of economic impact is important. It is necessary now as well that western governments are lashing about for what to do next.

One other issue.

Where are the foreigners and their families who remained behind in Wuhan. Where is Justin Steece, for instance? Remember “Wisconsin resident Samuel Roth has been on edge for the past two weeks. His wife and children have been stranded in Wuhan, China, the epicenter of a newly discovered coronavirus.” That was on February 4. On February 1 Time wrote “Justin Steece, Priscilla Dickey and their families were not on that plane [evacuating Americans]. Steece and Dickey, both U.S. citizens, are current residents of Wuhan.” Dickey got out days later “Dickey and Hermione had hoped to leave on the first evacuation flight out last week but couldn’t. This week, they boarded a flight charted by the US State Department to bring Americans home from Hubei province, where hundreds have died from the virus.” But others have family in Wuhan, right?



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