Anyone who has ever played a real-time strategy game knows that the most vulnerable moments often come early on in the struggle, before you’ve marshaled resources, educated your population, developed key technologies, and built a thriving economy. At that point, avoiding mistakes and executing with precision has enormous repercussions, but eventually, if you do everything right, a tipping point arrives, momentum becomes unstoppable, and triumph is guaranteed.
We’ve just started our moves.
As of Monday, twelve states had instituted stay-at-home orders affecting about one in four Americans. Only five states (Idaho, Iowa, Maine, Nebraska and Wyoming) still have schools open. One of the consequences of what might be charitably described as laissez-faire federal leadership is that local governments are making up their own rules as they go along, resulting in what is in effect a national laboratory of randomized experiments in how to contain Covid-19.
For example, on March 16, the San Francisco Bay Area became the first region in the United States to order shelter in place, at a point when only 335 cases of Covid-19 and six deaths had been recorded in the state of California (by contrast, Italy did not order a national lockdown until registering 9,172 cases and 473 deaths). The Bay Area and California writ large (which instituted a statewide stay-at-home order on March 19) will therefore be one of the first areas to generate useful data for epidemiologists on the impact of social distancing. Texas and Florida, two states that have taken more relaxed approach to implementing social controls, may produce data of a different kind—potentially indicating that a more lackluster response will result in higher growth rates for total cases and deaths.
What’s already happened elsewhere provides the background for current US policy. Italy’s shocking surge in deaths served as a key incentive to California’s precipitous action. The release last Monday of a dire report from the UK’s well-regarded Imperial College predicting as many as a million deaths from Covid-19 in the United States, even with “the most effective mitigation strategy examined,” further focused international policy makers on the pressing need for immediate, sweeping action.
Some critics attacked the Imperial College methodology and advocated for more aggressive containment strategies akin to China’s massive Wuhan lockdown or South Korea’s comprehensive testing and contact-tracing regimen, but public health experts cautioned against expectations that such models could be duplicated here. The United States, Jha says, does not have the bureaucratic or totalitarian capacity to put into effect a Wuhan-style lock down, and the moment when massive testing and contact tracing could have kept a national outbreak in check is long gone.
But Jha also warned against putting too much credence into any specific death toll estimation. “If anyone is completely confident,” Jha says, “you should not be listening.” (In support of Jha’s point, a survey of American infectious disease researchers conducted on March 16-17 estimated death totals in 2020 in a range from 4,000 to one million.)
Without any mitigation in the form of social distancing and stay-at-home orders, epidemiologists fear a massive spike in cases that will overwhelm the health care infrastructure. Spreading out that blow over a longer period of time has been the primary concern inspiring calls to “flatten the curve” by changing our behavior. But a second benefit of flattening the curve is that it also buys time to ramp up testing and understand where and how the disease is spreading.
The latest data from Italy, where the percentage rise of new cases and the total number of new deaths has fallen over the last two days, precisely two weeks after a national lockdown was put into place, is a heartening sign that aggressive social distancing measures do work. Jha speculates that over the next 10 days to two weeks the US is “going to see the exponential rise starting to shift and plateau. The percentage growth in cases will slow.” And over that same period, he says, much more extensive new testing capabalities will come online, something that we are already seeing in New York. “Not as much as I would like,” he says, but enough “to identify everybody who is infected and to do contact tracing.”