The public health case against coronavirus lockdowns

The framing of the lockdown debate as the novel coronavirus spreads has consistently been a trade-off between economic health and physical health: Either you ruin the economy or you kill tens, maybe hundreds, of thousands of people. It's a miserable choice.

I've argued for prioritizing lives over dollars because I can't see a way to accepting the ethics of the standard case for reopening the economy now. But what if long-term lockdowns aren't necessary to flatten the curve? What if they can even be counterproductive? What if there's a well-informed, prudent, and, crucially, humane argument for a different approach?

Lyman Stone thinks there is. Stone is the chief information officer for the consulting firm Demographic Intelligence, a research fellow at the Institute for Family Studies, and an adjunct fellow at the American Enterprise Institute. He's been sharing daily pandemic data analyses on Twitter, which is where I became familiar with his work, including a guide for churches responding to COVID-19. As he writes there, Stone's job at Demographic Intelligence has him advising "Fortune 500 countries and government entities about future population trends," so while he's not a doctor, he "routinely work[s] in detail with the medical and demographic literature around infectious disease, mortality risks, and especially fertility" and has been widely published on those topics.

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We corresponded by email (Stone is from Kentucky but lives in Hong Kong) to discuss his case against lockdowns as the best way to fight the novel coronavirus.

You've argued lockdowns — these stay-at-home or shelter-in-place orders now in place in nearly every state — aren't of significant benefit to public health, so prolonging them would hurt the economy without saving lives. What's your thinking here?

The first issue is defining "lockdowns." I define "lockdowns" with basically three traits: First, individuals are ordered to remain at home or expected to provide special proof of need to leave their home; second, assemblies are banned above a very low, usually single-digit threshold; third, a large number of businesses are ordered to discontinue operations.

Within lockdowns there's a lot of variety. Some states or cities enforce stay-at-home orders very strictly. Some do not. Some focus on assemblies. Others are more tolerant of assembly. Some close more businesses, some close fewer. But the basic features are stay home orders, low-number assembly bans, and ordered closure of numerous businesses. Most of the debate about lockdowns has focused on economic tradeoffs: We assume that lockdowns make COVID-19 less awful, and we assume they cause economic harms, and so we want to balance those.

I'm not sure of either side of that equation.

Countries without lockdowns like Sweden and the Netherlands are facing massive economic downturns, too. In a globalized society, you can't just turn a switch and turn your economy off and on. If other countries are in recession, you will be too. It's that simple. So I'm skeptical of the idea that not locking down will result in economics-as-usual.

Meanwhile, I'm also skeptical of the view that lockdowns make COVID-19 less awful. Daily deaths in Spain, France, and Italy have not appreciably declined over the course of their lockdowns. Academic research from China suggests that what actually got COVID-19 under control in Wuhan was centralized quarantine on a massive scale, not quarantining people in their own homes.

Hong Kong, where I live, has never had a lockdown and has been exposed to a huge amount of imported cases, and yet has avoided major spread and kept deaths at just four. Macau did a kind of soft lockdown, but nothing like what's happening in Italy. They had a successful response. Taiwan has not had a lockdown and has kept deaths very low. Singapore had no lockdown and was doing fine until it recently had a big outbreak — but note that Singapore has not had universal mask wearing and didn't cancel school until recently.

Nor is this a story of "Asian obedience." Just today I was out hiking in the supposedly-closed country parks in Hong Kong and saw every parking lot packed (on a Wednesday!) with thousands of other people hiking in the supposedly-closed country parks. Here in Hong Kong, our government downplayed COVID-19 consistently, and the population flagrantly broke anti-mask laws to wear masks. This isn't about obedience. It's simply about taking COVID-19 seriously and responding appropriately.

Moreover, lockdowns rely on a specific understanding of how COVID-19 works: Lockdowns assume that all COVID-19 infections are created equal and that exposure to COVID-19 because someone coughed on a cereal box you bought at the store is equivalent to sharing a glass of water with your spouse all day long for three days straight.

But what if this is wrong? What if viral load matters? In this case, we would want to avoid creating situations where people are cooped up together in enclosed spaces. We might look askance at the idea that keeping everyone packed in their homes is the optimal strategy. And we might worry less about folks having a picnic in the park.

Additionally, lockdowns are a very novel strategy. They were used on a limited basis to fight Ebola, but most Ebola-fighting revolved around capacity-building, changing burial practices, awareness-raising, and information provision. Broadly, information is the most powerful tool in epidemics. Fighting epidemics requires the cooperation of the whole population, which requires a massive task of public persuasion, information, awareness, and capacitation.

Relying on the cops to arrest people for going to Easter services does not fit that bill. More broadly, time-tested strategies like centralized quarantine and regional travel restrictions have been mostly eschewed in the U.S. despite being highly effective with literally millennia of supportive evidence.

Ultimately, I'm open to being wrong. When we've got good empirical studies showing that devoting state resources to harassing people for taking too many errands rather than delivering care packages of masks, hand soap, and information pamphlets is a good strategy, let me know!

The Trump administration has suggested lockdowns could end in parts of the country by the close of this month. If the strictest rules are lifted, what should we be doing instead? What measures are most effective?

Wear a mask! Wash your hands! Avoid unnecessary socialization! Leave extra space at the store! Keep school canceled! We should not be allowing a return to normal; that is extremely ill-advised. But even if the government moves toward normalcy, workers should still pursue working-from-home options; parents should try to keep their kids out of school; elders should continue to be sequestered; and excellent hygiene measures must be continued.

You've done a lot of pandemic data analysis, comparing international responses and infection and death rates. Many Americans who are skeptical of the lockdowns' value have pointed to Sweden as a model we should follow, as Sweden hasn't had a lockdown or the unemployment spike that comes with it. The pushback has been that Sweden's death rate was substantially higher than that of its Nordic neighbors, and Swedish leadership now seems to be wavering. Did Sweden make a good call? How does the Swedish approach differ from your recommendation?

I haven't followed Sweden's exact policies, and I don't know if their policies have been good or bad, but I don't see in the data any reason to think they are a miracle or a nightmare. Rather, Sweden seems to suggest that you can't avoid a recession by avoiding lockdown and also not locking down doesn't seem to lead to a very big spike in deaths vs. some plausible counterfactual.

But the "death rate" argument is ignorant and foolish. It is difficult to even get a reliable estimate of COVID-19 deaths, let alone a reliable estimate of total infections. Differential case fatality rates (CFRs) are more likely to stem from idiosyncrasies of the tested population or volatility related to low total outbreak size. Washington State has one of the higher CFRs in America, yet one of the more successfully contained outbreaks because the disease broke out in nursing homes, which made for relatively many deaths but not actually tons of contagion.

Anyone reasoning from CFRs in countries with very different testing regimes and total tests making up less than 0.5 percent of population is reasoning from complete ignorance. Someday, we will estimate infection fatality rates (IFRs) using excess mortality and serological studies. Until then, this is a policy-irrelevant variable.

You live in Hong Kong, which has handled COVID-19 differently than the United States. Can we learn from Hong Kong's approach, or are the differences simply too great between an East Asian city-state and a federalist country that spans a continent?

Yes, Americans can learn from Hong Kong. Wear a mask. All the time. Ignore the nonsense about face-touching or whatever. We don't wear masks to protect ourselves. We wear masks to protect others. You don't know if you're infected. And you don't know who else is either. Universal mask-wearing creates a powerful social norm which pushes precautionary mask-wearing onto possibly-infected individuals.

Policy-wise, epidemic-fighting isn't a national question. It's intensely local. The origin-story of modern epidemiology is a story about a cholera outbreak from one well. Hong Kong has about the population of a U.S. state (7 million). Its dense living conditions should have made spread worse, and yet we're doing fine. How? We centrally quarantine anyone who tests positive and everyone they have contact with. If somebody at the office tests positive, the entire office goes into a designated quarantine site for 14 days.

Any U.S. city could do this. Any American can wear a mask. Just do it. This strategy works.

President Trump's claim of "total" authority to restart the economy was both unconstitutional and nonsensical — he can say what he likes, but people aren't going to resume normal life if they feel unsafe. If you had the president's bully pulpit, how would you describe the risks and the way forward given what we know about the novel coronavirus so far?

First, I would suspend funding to the World Health Organization (WHO) [Trump did this Tuesday after our interview began], recall all U.S. government personnel detailed to the WHO, announce a sanctions-related investigation into WHO leader Tedros Adhanom Ghebreyesus' conduct as minister of health in Ethiopia during the covered-up cholera outbreaks, and announce that individuals and organizations associated with Tedros may be caught in that net as well. I would further announce that if Tedros steps down, the WHO officially states that China's suppression of information about COVID-19 caused a global pandemic, and Taiwan's 2009-2016 access to the WHO is restored, funding and U.S. support will be restored. I would commit to going to war against the WHO until either they give in or we so degrade the organization that it can no longer function. [You can read about why Tedros and the WHO have come under criticism for their handling of China and the early days of the pandemic at The Atlantic and The New York Times.]

Second, I would never appear in public or on TV without a mask.

Third, I would repeatedly communicate the truth: We are likely to be fighting COVID-19 for a long time, and many people will die. Steel yourselves. Do not plan to return to normal in 2020. Advise state governments to be working on plans for continuation of heightened risks through the summer of 2021. Speak repeatedly about the need to roll out ever-more-extensive telework, telehealth, and work-from-home arrangements. Communicate about the importance of mutual care and aid. Remind people that stimulus checks are coming, unemployment insurance is extra generous, and more stimulus will be provided if things go on too long. Remind people that even when current drastic measures end, we are going to spend a hot, humid summer wearing face masks while jogging.

Get over it. It is a small price to pay.