1. Occident and Orient. It is difficult not to notice the striking difference in coronavirus cases and deaths between places like New York and Italy on one hand, and Oregon, California and South Korea on the other. It is tempting to wonder whether there is some intrinsic difference in the virus that afflicts western Europe, and which may have then spread to the eastern United States, and the one in east Asia that may have then spread to the western United States.
2. Who dies. It is possible that we have reached the point in the spread of the virus, and the resulting suppression of everyday activities, where we are now trading off some deaths against others. It is possible perhaps that preventing the coronavirus-related death of an 80 year-old cancer patient will result in a fatal heart attack in a 68 year-old diabetic, because "routine" care that would have prevented such an outcome was foregone in the interest of "social distancing." The same may be pondered regarding the 85 year old Alzheimer's patient who persists three weeks on a ventilator, while another patient has a massive stroke because his endarterectomy for carotid artery disease was considered "elective." It is certainly possible, if there is a second wave of infection, that at least someone who would have gotten the infection the first time around, survived and developed immunity, would succumb of avoiding the infection the first go-round but acquiring it in the encore.
3. Decision and policy-making. It has been argued, by authors such as Malcolm Gladwell, if I recall correctly, that specialists have deeper knowledge but that generalists make better decisions. This is at least plausible, and if true suggests that the present approach of having political leaders, who are elected on political criteria, not leadership capacity or a history of wise decisions, deferring to the advice of narrowly credentialed experts is not optimal. Experts bring a blind-men-and-the-elephant narrowness to their opinions. They should not be expected to see the big picture, but then neither should the politicians. Experts have an interest in their fields, politicians have an interest in politics, but neither of these necessarily results in good policy. Throw in that the experts do not know nearly as much as they should, and the politicians have other interests that compete for consideration, and one would not expect policy to have nearly the beneficial effect on the epidemic as other factors.
4. What was necessary. The previous point naturally leads to another: what interventions that have been prescribed by various governments and organizations had the most effect on the spread of the virus, if any of them did? The experience of New York may well be considered a worst-case scenario. Whether it was virulence of a particular strain, the peculiarities of the public transportation system, population density, incompetent response, or likely a combination of multiple factors, it is obvious that what worked elsewhere did not work in New York. From this we may conclude that certain interventions were ineffective, either because of environment, virulence, demographics or other factors, and that these ineffective interventions could have been foregone. So what worked elsewhere?; Was it necessary to "shelter in place" and shutter large parts of the economy? The experiences in Sweden, South Korea, and South Dakota suggest that, in certain environments, the answer is "no." The key factor is what interventions impede the most efficient means of spreading the virus. Given what we know, it seems at least plausible that the planet would have the same ball-park number of cases if the interventions were limited to: wearing masks, eating most everything with a clean utensil rather than hands, sanitizing hands after touching objects that the general public touches, such as door handles, light switches and plumbing fixtures.
5. Factors. It seems obvious that there is no one factor that accounts for the differences in COVID-19 experience between New York and Washington State. The difference is not due to smoking habits, ventilators, age, or the subway. There are likely multiple factors which formed a perfect storm around New York. The "lockdown" interventions may have had some positive effect, but more significant factors overcame them. There likely was no amount of mandated social distancing that was going to contain the spread of coronavirus in New York, and no intervention that was gong to keep the case fatality rate commensurate with South Korea or Germany.
6. Probabilities. It is helpful to think of the virus and the disease that it causes in terms of probabilities: each exposure has a certain probability of transmitting the virus, each case has a certain probability of being asymptomatic or minimally symptomatic. Each severe case has a certain probability of ending up on a ventilator, and a certain portion of those, of dying. The idea of interventions is to lower the undesirable probabilities. Wearing a mask likely has some modest effect on the probability of transmitting infection from an infected person to an uninfected one. Interventions such as remdesivir and hydroxychloroquine likely decrease the probability, without making it negligible, of proceeding to more severe disease or resulting in death. The goal of intervention is reasonably to lessen the probability of undesirable outcomes keeping other valid concerns, such as the economy in mind. At a certain point, more and more stringent restrictions hit the point of diminishing returns so that they induce harm more than mitigate risk.
7. Models. Models have not fared well in this crisis, for the simple reason that they have not provided accurate, or in some cases even reasonable predictions. This observation is not limited to epidemiologic models; it also applies to economic and even political ones. One flawed model is that expressed by Governor of New York that if severe restrictions "save one life" they are worth it. This is a hopelessly flawed model of the facts. There is no way of measuring either the cost or the benefit. If a person's life is "saved" until he tests negative for coronavirus, only to die of a ruptured brain aneurysm a month later, has a life been saved? What sacrifices were justified by this outcome? Furthermore, this reasoning does not translate to other concerns. It is difficult, for instance to apply the same reasoning to the distinction between "essential" and "non-essential" businesses. If a business is essential to just one person, say, the owner, is it essential, such that it is arbitrary to distinguish between hardware stores and hairdressers?
8. Assumptions. The news and social media are full of unjustified assumptions. One is that distinguishing between essential and non-essential provided anything more than a cosmetic benefit, beyond what what people could achieve themselves by observing reasonable behaviors to minimize the spread of the virus. The second, related one is that "emergency powers" and draconian restrictions were necessary or even helpful. A third is that a person who is infected with the virus is therefore immune, and that a vaccine is a foregone conclusion. None of these are beyond doubt. There is an argument to be made, but it is just an argument, that "flattening the curve" saved lives. No one knows. There is an assumption that some insight lurks in comparing the 2009 H1N1 epidemic with this one. The differences are significant, not the least of which is that H1N1 is from a class of viruses for which immunization has been shown to be an effective strategy.
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