By Gordon hull
The coronavirus outbreak showcases a lot of what is wrong with the Trump administration and the stupid, preening narcissist at its head (this is a president who claimed not to have known that flu kills thousands of people every year – but whose own grandfather was a victim of the 1918 pandemic). At the Washington Post, Jennifer Rubin thinks that coronavirus is likely to bring down the entire GOP house of cards in November, as it relentlessly exposes the corrupt ineptitude of Trump; as goes Trump, so go his sycophantic enablers in the Senate. This would be karmic. It would also be no comfort to the many, many people that Donald Trump is about to kill. Indeed, not just the actions of Trump’s egomaniacal incompetence but our collective need to think about it (guilty!) is itself part of why we aren’t prepared.
That is, people will die because the failure of the government to do anything meaningful towards containment in the early stages of the epidemic, in no small part because of Trump’s narcissistic dithering and lying. Even now, as we’ve moved from “containment” to “mitigation,” nowhere near enough people are being tested. This makes it much harder to know who is at risk of contracting the disease and spreading it to others, which in turn makes it more likely that they do so. More people will get sick. Not testing enough people also makes it impossible to know how deadly the disease is, because it denies you a sensible denominator for predicting the case fatality rate. When Trump said he had a “hunch” that the WHO’s widely-circulated 3.4% fatality rate was too high, he was probably right (with lots of provisos) – but his own stonewalling on testing make it impossible to substantiate the point. Trump will also kill people through his prior stupid policy decisions, like forcing asylum-seekers to wait in Mexico until their number is someday called, in makeshift camps that lack even the running water necessary for hand-washing.
Against this bleak background, a post at The Incidental Economist offers some sobering back-of-the-napkin calculations. Based on extrapolating from what we know about the case fatality rate in Wuhan and varying it up or down, and combining that with two attack rates estimating the percentage of the population that gets Covid-19 (the 5% rate for seasonal flu and the 19% rate on the Diamond Princess cruise ship), they conclude:
“Even under our most favorable scenario, roughly 133,000 people will die. Of greater concern, if we assume that US Covid-19 is half as lethal as the Wuhan data, then under a plausible 19% Attack Rate, there would be half a million deaths. Under the least favorable scenario, 1,000,000 will die”
Although they underscore that these are very, very rough estimates, they are staggering. These numbers could be off by a lot, and still be very bad. They also allow one to underscore a short-term and a longer-term point.
First, in the short term, we need to do everything possible both to slow the spread of the epidemic (“flatten the curve”) and deal with a likely explosion of cases. Failure of the former makes the latter both more likely and worse. There’s two overwhelming reasons for this. One is that there is a real risk that if the epidemic suddenly spikes, the healthcare system could be overwhelmed. There simply aren’t enough hospital beds for everyone who is likely to need one, and Italy provides a sobering example of how quickly a system can be strained beyond capacity. Slowing the spread eases the burden on the healthcare system as a whole, and makes it more likely to be able to adequately care for those who come to it with Covid-19. Hospitals are frantically trying to prepare while President Nero plays golf; national focus and resources are urgent. Second, and this was the point of the Incidental Economist post, if you want to bend the fatality rate down, you need to stall until there are some plausible antiviral treatments on the table. Not a vaccine – that’s still a long way off – but medicines that mitigate infections, save lives, and keep people out of intensive care and the ER. Gilead is working on one; a recent comment in the Lancet outlines recent AI research into other possible efficacious treatments. The point is that these things need time to come online.
When they do, they will be expensive. The Incidental Economist post estimates a range of $21 to $165 billion to treat everyone who shows up at the hospital and needs them (so not treating people with milder infections. Only those who need hospitalization. This is not your Tamiflu prescription!). A lot of them will be senior citizens and covered by Medicare, but many will not. That’s enough to bankrupt private insurers, and cause massive problems for Medicare too. If Congress would like to spend some money, making sure that treatments are affordable would be an excellent place to do so.
(There’s a potential IP showdown here. The international IP agreement, TRIPS, includes a provision for compulsory patent licensing in the event of a public health emergency. Pharma doesn’t like this, but that doesn’t mean it shouldn’t be on the table if the price is too high)
Now, the long term point. Covid-19 provides a very good illustration of the fact that public health is a public good. Public goods are non-rivalrous (any number of people can consume them without using them up) and non-excludable (you can’t prevent someone from benefiting from it). They are also under-supplied by markets because it’s hard to make money selling something that never gets used up and that you can’t stop people from sharing. Public health is in fact one of the standard textbook examples of a public good; the other is national defense. Relying on markets to supply public health is exactly as stupid as relying on markets to supply national defense.
But of course the entire U.S. healthcare system is premised on markets, and public health is radically under-funded. As a result, we undersupply public health and things that would support it, like vaccine research or access to healthcare for everyone. Yet we know that the massive gains in life expectancy over the last century are largely attributable to public health measures. Awareness of that by those who study health doesn’t guide politics, though. In May 2018, the person in charge of U.S. pandemic response abruptly left the NSC and was not replaced, meaning “no senior administration official is now focused solely on global health security.” As the Washington Post article I quoted explains, you can thank John Bolton for that (so maybe don’t line his pockets any more by buying his stupid book, even if he didn’t like the Ukraine policy. He is as bad as the rest of them). Here in North Carolina, the Republicans in the state legislature have refused to compromise on a budget because the Democratic governor has drawn a line in the sand over Medicaid expansion. Why, other than a visceral dislike for Obama, will they not expand Medicaid? They have no good answer. But as a result, hundreds of thousands of North Carolinians will find it much harder to get medical care (or even tested) for COVID-19. That doesn’t just mean that more of them will die, or end up in Emergency Rooms receiving charity care. It also means that they will make more people sick in the larger community. Markets undersupply public health, and the absence of a true public health policy will literally kill people – and not just the ones who cannot afford to buy health insurance.
For another, maybe even more disturbing example: COVID-19 is genetically very similar to SARS. Researchers in Texas had done a lot of the work towards a SARS vaccine several years ago, and there is good reason to think that it would at least help with COVID-19. Do we have that vaccine? Of course not. There was no funding. To be sure, this is a global problem. But the U.S. is the world leader in pretending that markets solve all problems. Whenever and however the COVID-19 epidemic ends, it is way past time for awareness of the importance of public health and to actually listen to basic economics long enough to stop believing markets will provide it. In public health as in national defense, we all go together.
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