A flattened curve: Now what?

Over the past month, the United States and the rest of the developed world, has locked down the vast majority of their populations in order to “flatten the curve” in the battle against COVID-19. This strategy worked; rates of growth of new infections are falling.

The question facing societies around the world is “Now what?” The first-best option – vaccinate the entire population – will not be available for another year to 18 months. Societies have to choose from a menu of second-best options. They are being forced to make tradeoffs among mortality rates, economic activity and personal liberty.

Some public officials in the United States, such as California Governor Gavin Newsom, are advocating for a strategy that prioritizes low mortality rates that can be summarized as “quarantine everyone.” This approach is non-discriminatory, because everyone is treated the same; it protects the elderly and medically vulnerable, who seem to have COVID-19 infection and mortality rates that are much higher than those of the general population; and it keeps the government (and employers) from intruding into citizens’ medical privacy. The tradeoff is a shut-down of the economy that may cause a depression not seen since the 1930s. It is therefore not politically sustainable. COVID-19 is not the only thing that grows exponentially; so do business failures, layoffs, mortgage defaults and voter discontent.   

A variant of the “quarantine everyone” strategy is to couple it with antibody testing, so that those who are immune can go back to work. What the promoters of this approach fail to mention is that the more effective the quarantine is in keeping everyone virus-free, the fewer immune people there will be to go back to work. Antibody testing is simply window dressing on a “quarantine everyone” strategy.

An opposite strategy – one that prioritizes personal liberty and privacy – was tried and then abandoned in Britain and New York City and can be summarized as “quarantine no one.” It is now being forced upon the world’s poorest countries by their low state capacity, lack of an economic cushion and crowded cities. Citizens with the resources to do so can isolate themselves; everyone else is exposed to infection.

This strategy has only one thing to recommend it; herd immunity is reached quickly. The tradeoff, however, is excess mortality among the elderly and those with medical conditions co-morbid with COVID-19. This strategy also runs the risk that, as happened during medieval epidemics, skyrocketing mortality rates induce people to refuse to transact with one another, thereby causing the economy to collapse just as if everyone had been quarantined. If the death rate climbs fast enough, and the depression is deep enough, social order may break down.

A middle of the road strategy – one that prioritizes both economic activity and low mortality –was adopted early in the pandemic by Singapore and South Korea. It can be summarized as “quarantine the infected.” Everyone else can continue to work. The tradeoff is that it requires mandatory testing on a massive scale to identify the sick and the asymptomatic carriers, who are then forced into quarantine. The government must then test everyone with whom the sick and the carriers have been in close proximity (typically by using individually-referenced cellphone location data) and quarantine those who test positive. This program of mandatory testing, tracking, and quarantining must be sustained until a vaccine is developed; herd immunity is ruled out by design. Thus, citizens must be willing to accept a high degree of state intrusion into their lives. In many countries, such as the United States, this may not just be politically unpalatable, it may be legally impossible. 

A final strategy, which has emerged in countries such as Sweden, can be summarized as “protect the vulnerable.” This strategy exploits the large differential in the mortality rate from COVID-19 between the general population and the elderly, as well as those with medical conditions that are co-morbid with COVID-19. The young and the healthy can go about their business, while building herd immunity, so long as they work together to keep the vulnerable from becoming infected. To cite but one type of such working together, people who have obtained immunity from previous COVID-19 disease, or who turn out to test positive for COVID-19 antibodies, run errands and cook for the elderly, rather than have the elderly rely on their perhaps-infected, but asymptomatic, children. 

This strategy is not without tradeoffs. A large segment of the population must be willing to become infected. While the average mortality risk of the general population is low, it is not zero.

A “protect the vulnerable” strategy also has two necessary requisites, which may complicate its implementation in countries such as the United States. It requires that government officials and the mass media now separate in the public mind concepts that they allowed the public to conflate. 

“Flatten the curve,” properly understood, meant reduce the rate of growth of new cases so that hospitals would not be overwhelmed in the early days of the pandemic. It came to be understood – at least in the United States – as “the unusual virulence of COVID-19 requires minimizing the number of people who will become infected until a vaccine is developed.” This conflation was perhaps necessary to get people to go along with a “quarantine everyone” strategy. It also proved to be an attractive business model for media companies to capture eyeballs and advertising dollars. It is, however, not consistent with the report that found that the risk of dying from COVID-19 is an order of magnitude larger for the elderly, and now stands in the way of shifting to a more balanced course of action.

A “protect the vulnerable” strategy also requires citizens to set aside differences and actively embrace cooperation. Helping strangers cannot be accomplished by government mandate. For those who believe that government is the solution to every problem, this approach may be politically unattractive.

Alexander Galetovic is a senior fellow at the Universidad Adolfo Ibáñez in Santiago and a research fellow at the Hoover Institution. Stephen Haber is professor of political science at Stanford University and a senior fellow at the Hoover Institution.