[Claus Offe] Thursday, April 30th, 2020
Six Categories of People.
Demographic and epidemiological models divide the population precisely and fully into up to six categories, such as:
(1) Those in the resident population not infected with the Corona virus
(2) Those actually infected, though not diagnosed. The quantity of this category is a major unknown because of limitations of the supply of capacity of testing or/and the asymptomatic condition of those infected which leads them to refrain from seeking testing. Schools of epidemiologists (e. g., researchers at Imperial College London and Oxford University) differ on estimates of the size of (2). A widely shared assumption seems to be that the non-diagnosed yet infected number five to ten times of those who have tested positive, a number that can be validated only with adequate testing practices.
(3) Those who tested positive, the statistic of which cumulatively denotes the incidence of cases since the beginning of the cycle of the epidemic. Thus it includes members of categories (4) and (6), the meanwhile recovered and the deceased.
(4) Those who have recovered from an infection and are now considered immune. The duration of immunity and hence the possibility of re-infection seem to be uncertain so that a return to (2) cannot to be excluded. Not included here is the (again unknown) number of those who have recovered without having suffered from any or severe symptoms, thus having directly moved from (2) to (4).
(5) The percentage of (3) who require treatment (about 20%), including ICU treatment and finally
(6) Those who have died because of (or just with) the virus infection (with the addition, arguably, of all those who have died from other diseases which they could have survived if the health system had not been overwhelmed by Corona cases). The validity of such data is contingent upon, among other things, the capacity for autopsies and the registration of those who have died not just in hospitals but at home. Another measure is the size of a spike in the overall mortality statistic that coincides with the virus pandemic.
If this is correct, one can, for example, test the following connections:
- The greater the value of (1), the stronger the growth of (2) plus (3), and, after some period of time, the reverse (due to “herd immunity”)
- The greater (2) minus (3), the greater will be (6), and by extension the smaller by definition will be (1)
- The greater (4), the lesser (6)
- The greater (2) plus (3), the greater will be (6) (with unexplained, strongly varying death rates as long as the reference figure – the total of those actually infected – is not known and standardized for international comparisons).
Such model calculations cannot, however, be performed empirically, simply because all six categories are missing valid quantification, i. e. data which are either generated by compulsory administrative reporting or compiled through research and diagnostic testing procedures (with their partly unclear validity and specificity). In addition any quantitative measure would be strictly time-indexed as the size of these categories is constantly shifting throughout the cycle of an epidemic.
At the beginning of the cycle, the whole population finds itself in (1), and from there all categories grow until (2), (3), and (5) are eventually all but empty and the surviving population falls exclusively into either (4) or (1). It is crucial to see these cycles in context by trying to recognize the given moment in the timeline of the crisis, the availability of diagnostic materials and staff, the capacity for quarantine and social distancing enforcement and compliance, the preventative health measures taken by (1), the social and state regulation of distancing between (1) and (2) plus (3) and the relationship between supply and demand for/from (2) concerning tests and the validity of the results these produce.
Policies.
Policies seem currently to focus strategically on (parts of) (1). This seems to be the case even though those who fall under (1) cannot – because of the possibility of even asymptomatic transmission from (2) to (1) – be reliably separated from categories (2) through (4)). The effective enforcement of “social distancing“ and other forms of “shutdown” is being pursued with the goal of slowing the cycle of the epidemic because it recognizes the lack of infrastructure – testing capacity – available to decrease the difference between (2) and (3). While this shortfall can be tied to financial, medical, and even legal variables, it results in a growing sum of (2) plus (3), while further raising the volume of (4). There is, however, a difference that opens up between (2) and (3), even without considering the unrealistic possibility that the entire population (again: random tests are not sufficient!) is tested weekly in the hope of creating a “segregation” between (1) and (3). This difference arises out of a number of facts, namely that
(i) many of those infected have not (yet) themselves shown symptoms but can nevertheless infect others,
(ii) that the symptoms are so weak that they do not (possibly because of their own awareness of the limited amount of available test materials) ask for a test, and
(iii) that the capacity and availability of diagnosis does not meet the demand.
But, while the development of a self-administered, serological “flash test” could signal substantial progress, the potential of such a resource could still only be harnessed if those who have tested positive would be disposed for ethical reasons to comply with rules (wearing masks etc.) that are designed to protect the non-infected individuals in category (1).
By contrast, a (politically completely unrealistic) “libertarian” solution of “doing nothing” would consist of allowing the infection to simply run its course and so, after a relatively short amount of time, reach a state in which the population has divided itself (if only with hermetically sealed borders) into (4), a remaining percentage of (1), and a very large percentage of (6).
But that is not all there is to it. A paradox to consider is that the more successful the preventative behavior of (1) and the reduction of the reproduction rate R (to a value >1 but <3) turns out to be, the slower the growth of (4) and the longer the crisis must be expected to last and the greater the chance of those currently in (1) to be infected at some later point. A shared assumption of epidemiologist seems to be that the percentage of the population that must have wandered from (1) to (2) and (3) and finally to the immune status of (4) is 60 to 70 percent. If this is true, it will take many years if infections are slowed down in the interest of protecting the health system from being overwhelmed.
The socially, substantively and temporally generalized version of social distancing, which applies to all residents and (nearly) all occupations except “essential” ones, and which sets a generally assigned period of time to be effective for all, is justified by the argument that it can help in winning time – time for the building of additional treatment capacity, the development of pharmaceutical remedies and, first and foremost, the protection of clinics from an overload of cases in which triage becomes necessary. This all comes under the imperative of “flattening the curve”. One could, however, just say that these measures are causing us to “lose time”, because the amount of time in which the members of (1) risk being infected is itself becoming longer. The flattened curve extends for a longer distance into the future. If, as is assumed, the crisis ends only when we have reached “herd immunity”, then this end will only be postponed by the implementation of non-pharmaceutical interventions (NPIs) currently implemented.
The Discriminatory Effects of Lockdown.
Interpreted through the lens of game theory, the following collective action problem emerges: Every member of (1) hopes (and does everything to the effect) to stay there permanently by avoiding infection through voluntary NPI measures. They thereby not only achieves protection of individual health but, in addition, the protection of the health system from overload (which would result in an increase of (6)), while, on the other hand, extending the duration of the crisis and an extended risk of the individual’s infection at a later point. Yet a modern society cannot “wait” until the pandemic has run its course. The economically extremely costly shutdown of economy and society cannot be sustained over a “long” period, and the less well-off people are the less likely it is that they can afford to have their normal life interrupted. It is due to these gigantic and highly unevenly distributed economic, social and psychological costs that a “long” waiting period is entirely intolerable and politically de facto unacceptable, even if we disregard for a moment the legal constraints resulting from a minimally liberal constitutional and legal order that does not allow for the emergency suspension of all kinds of civil rights. The resulting dilemma seems to be as follows: Every person in (1) is interested that, with the maximum effort spent on his or her self-protection, the greatest possible number of other people in (1) will actually be infected so as to shorten the time at which collective immunity is reached. Once “my” fellow citizens have passed from (1) to (4) (or, as the case may be, to (6)), all of us survivors would happily arrive in a virus-free world and “I”, having never left (1), would be the healthy “winner”, a “free rider” on the less fortunate health career of others. All this is valid only under the assumption (and the continuing validity of this assumption) that (i) there does not emerge some effective pharmacological relief (preventative as in the form of a vaccine or, therapeutic in the form of a medication) which is available on a massive scale and that NPIs remain the only available action parameter, and that (ii) it proves impossible to reduce, and reduce permanently, the reproduction rate of R to <1 through NPIs alone.
An overload of the health system through the capacity-exceeding occurrence of (5) leads to unavoidable triage-decisions, that is, death sentences which are normally barred by our conception of basic liberties (think of the principle of Menschenwürde [“Human Dignity] as per Art 1 Grundgesetz [German Basic Law], or the “Recht auf Leben” [Right to life] per Art 2 of the German Basic Law). The absolute normative superiority of the goal of “survival” that is being pursued through “flattening the curve”, “winning time”, “extending the lockdown” and “building clinical capacity” measures will, I predict, be ever harder to maintain and implement in political terms, however, because the same regulations which apply evenly to the entire population do evidently neither burden nor benefit all members of the population evenly. For while the benefits (survival through adequate hospital capacity) apply mostly to severe cases of elderly males with pre-existing conditions (who make up the bulk of our category (5)) the cost burden and painful disruptions of normal life are borne by the population in general and, in particular, by people in socioeconomic condition who can least afford the deprivations of the lockdown.
Authors have spoken of the trade-off between “life” (of those most at risk) and “livelihood” (of the vast majority), or simply of “health” vs. “wealth.” While the structural conflict between the beneficiaries of the lockdown and those deprived by it is not yet well articulated and clear-cut, the two sides begin to polarize in Europe and North America in the second half of April 2020. On the one side, those who can, for the time being, relatively easily cope with the restrictive measures because they are pensioners or enjoy the privilege of working from their home offices emphasize that the restrictive regulations in force serve everyone in society and are necessary to overcome the corona crisis. On the other side, the voices get louder who argue that the social and economic situation, both in families with school children and in shops, stores, restaurants and firms has become unbearable and that the lockdown itself has also turned life-threatening rather than life-saving as it fuels physical violence and severe psychic distress and depression. A growing number of commentators seems to take pleasure in observing that the cure of restrictive measures lead to outcomes that are worse than the disease itself. After all, they point out, members of the senior population under quarantine can also die as a result of depression and loneliness. In addition, there are more and more reports of younger men physically abusing their wives and children under the stress caused by the long lockdown.
Complaints about the denial of freedom – from labor market access to the right of assembly to religious worship – become increasingly more prominent, and legal scholars together with leading politicians have tried to convince mass publics that the right to life and access to life-saving medical facilities does not deserve to be given absolute priority over all other rights. The discourse is being reframed so as to highlight all kinds of damages associated with the lockdown and to spread doubts concerning its universal benefits. Claims emerge to the effect that general social distancing restrictions do not in fact do very much to serve anyone’s “survival”; even if they did and provided additional protection to particular elderly high risk categories of people, that would anyway apply only for a limited number of remaining years of their life time, a time likely to be spent in precarious health conditions, sometimes measured in the unit of “quality adjusted life years.” Tens of thousands of people die each year – or in waves happening every few years – from influenza, without policy makers seeing much reason to take notice and intervene. Why should they act differently in view of an epidemic that (according to some) is not dramatically different a threat for most people? This applies all the more as the high risk segment of the population whose survival is at stake will just have to wait for a year or two until an effective medication is available, while the vast majority of the population will have to suffer indefinitely under the war-like destruction inflicted by policies of lockdown that are bound to destroy much of social and economic life.
Once this perspective on things has sunk in, there remains nothing to bemoan in the conclusions drawn by officials and experts that there cannot be an absolute priority for saving lives at the expense of all other concerns. Proponents of this view suggest that it is ethically at least questionable, while legally hard to justify and politically almost unenforceable, that “the right to life” should, for everyone and under all circumstances, take precedence over other human and civil rights. Also, the opposite claim that combatting the virus to save lives must take absolute precedence over nearly all other rights can lead, as the current Hungarian case and in part also Polish ambitions indicate, to the irreversible establishment of authoritarian regimes. The bottom line is that we must be warned against despotic uses governments may be tempted to make of measures they adopt in the name of protecting our lives and our health.
The counter-argument of those opposing the “premature” loosening of lockdown measures claims that the threat of being severely affected by Covid-19 applies to all, not just to the elderly high-risk category. Moreover, and normatively speaking, the state has no right to violate the “right-to-life” principle by knowingly and intentionally failing to provide citizens in need with available medical facilities and regulatory arrangements that might help them to survive. We’ll have to watch how this conflict of interests and reasons (which in addition is fuelled by strong emotions) will evolve as the crisis runs its course. But it seems exceedingly risky to predict that the latter arguments for staying the course of lockdowns and stay-at-home quarantine will prevail in the face of the giant accumulating costs they are ever more evidently causing.
Governing the lockdown.
Yet there is one set of pragmatic considerations that makes it difficult for government policy makers to depart from the course of strict precautionary counter-measures against the pandemic once they have been adopted. Given the constant comparative attention of the mass media to the global nature of the pandemic, every national government is permanently under scrutiny as to its relative performance in terms of both “health” and “wealth”. Governments have very good reasons to fear the loss of their legitimacy, support, and also international reputation in case they can be depicted as failing to cope with the most elementary function any government is expected to perform: that of providing protection to their people. If in comparison to other “comparable” governments it blatantly and conspicuously fails to perform this function, it has to face the very distinct possibility of losing political power. Once a government has recognized the need for action and adopted intervention strategies (and how could it do otherwise, given the severity of the Corona pandemic which does not allow for the “benign neglect” practiced in normal influenza epidemics?) the irreversibility logic of a ratchet effect sets in. As the cases of the American and Brazilian presidents may serve to illustrate, the response of denial and inaction tend to rapidly evaporate as an option. After some kind of action has been taken, capitulation and a return to the inaction of some status quo ante are no longer options as long as stated policy objectives have not been met. What used to be a fateful event at a later point becomes seen as a policy mistake because the government has not adequately responded. For if a retreat were undertaken, conceivable consequences of such a move (e. g., a sudden rise in the number of fatalities following upon a “loosening up of restrictions”) could no longer be accounted for, as before, as an external shock for which nobody can be blamed. Once a calamity has been recognized as a challenge for action, it remains on the government’s agenda until a viable response has been found, particularly if the comparative perspective of evaluating other governments is kept alive. When under intense scrutiny, governments cannot painlessly abandon previous commitments. The driving motive of policy making can become a selfish and arguably irrational urge of ruling politicians to avoid blame.
To be sure, there are policy designs the authors of which claim to build a bridge across the wealth/health dilemma. Lockdown and stay-at-home regulations can be issued as blanket orders to be applied to the entire population with few functionally grounded exceptions. Slightly less rigid is a restriction on the types of activities for which one may leave the house. For instance, the movements permitted are limited to travel to/from work, grocery shopping, visits to the doctor etc. These two types of restrictions – blanket vs. selective – can be put in place for longer and shorter periods of time. The policy designs currently under discussion propose to turn away from such general regulations and replace them with specific and differentiated ones, a move which will supposedly also strengthen the disposition for compliance on the part of citizens. The idea is that of targeting high-risk categories of people, activities, and places with restrictive measures while all others are allowed to return to “normal” patterns of mobility and activity. In this way, “unnecessary” restrictions would be lifted and only those are kept in place that are deemed necessary.
This means that all those in category (1), especially risk-carrying people, determined by gender, age, medical records, region, and individual contact history, will be liable to specific regulations (or, in reverse, exempted from specific regulations) through the logic of targeting, testing, and tracking. Rather than placing all residents under social distancing protocols, these are only applied to specific groups, such as to those who exhibit a specific clinical picture or who return from traveling in hard-hit countries or regions. Especially the rapidly growing numbers under category (4) are to be “liberated” through (certified) negative test results and have their civic rights fully restored, while those who fall under (5) and carry high risk (for themselves and for others) are to be subjected to special protections and restrictions. Under the assumption that those having overcome the infection are permanently (or at least until vaccines become available) immune and do not carry any continuing risk of infection for others, it cannot be justified that those in category (4) continue to be subjected to the restrictions which may indeed be reasonable for the part of the population under categories (1) through (3). On the other hand, it seems normatively problematic if high risk groups – risk for themselves, for others, and for the capacity of the hospital and health care system – are “only” subjected to the same restrictions as other, safer groups.
For such a differentiated design to work, however, valid information is needed as to what level of risk applies for how long to what category of people and activities. Yet such information is either hard to establish (How can one know who has just returned from visiting a hot spot of intense viral infection and is thus likely to spread the virus after returning home?) or it is intensely contested (Why reopen stores of up to 800 square meters while much smaller daycare facilities remain locked? Why open restaurants but not bars?). The more detailed the rules on what is permitted from when on or banned up to what point in time, the more contested these rules are likely to become in terms of their legality, proportionality, and fairness. The more reasons given for a differentiated regime of shutdowns and schedules for the reopening of operations, the more reasons to object. Even if we had information that is recognized as valid by virologists and other experts, the regulations based on it are extremely hard to enforce: As long as everybody is subject to a stay home order, it is relatively easy to police. Yet not so if it applies differently (or not at all) to various types and categories of people, a condition rendered even more complex if risk categorizations must be frequently altered as the situation changes. In any case, the degree of compliance with regulations is largely contingent on self-imposed discipline, enlightened understanding and informal sanctioning, not formal policing. These civic dispositions are likely to vanish the longer restrictions last and the more they are perceived as arbitrary or excessively cautious.
Stratification.
The Corona pandemic leads to new patterns of stratification. Privileged in terms of health is the working age population, children and youth with robust immune systems relative to seniors. Workers with a home-office option are much better protected from health risks than others. People in weak and precarious socio-economic conditions (grocery store clerks, care-workers, nurses, delivery drivers, residents of refugee shelters etc.) are most vulnerable in terms of both economic and health risks. The facilities and capacities for home schooling are very unevenly distributed, with kids of educated middle class households in reasonably spacious apartments enjoying huge advantages. Millions of employees as well as self-employed small entrepreneurs are being put out of business, while pensioners suffer no economic risk. Most economic risks, one might speculate, would be somewhat more easily sustainable if a basic income scheme were in place as a universalist economic safety net. As it stands, public policies are far from capable to compensate for these and other compounded health-and-wealth inequalities, and particularly so in view of the foreseeable economic negative-sum-game that will come with unprecedented rates of negative economic growth of unknown duration. For the time being, public policies respond to the crisis by creating huge volumes of emergency funding for subsidies, loans, and transfers. They also concentrate on providing for the health protection of select categories of people in order to prevent an overburdening of the health system, such as:
- Clients of clinics and facilities for old-age care as well their employees who are threatened by in-house infection (the so-called “nosocomial” risks),
- Persons of an advanced age (the average age of Corona-related fatalities is reported to be 81 years),
- Persons with a variety of pre-existing conditions.
Additionally, many EU member states focus on preventing the further “import” of the virus by establishing strict border regimes between states and also regions. The economic burdens of maintaining and upgrading the health and care system serving the elderly weigh heavily on the younger and middle generations, while the gain, to overstate the point, is largely enjoyed by multi-morbid retirees with pre-existing conditions whose remaining span of life the strategy is designed to increase. It is tempting to predict the manifestation of a generational conflict here. At any rate, we should not be surprised if the Corona pandemic, when it has been overcome at some point in the future, might retrospectively be viewed as an essentially geriatric issue.
The more such a “generational” reading or framing of the situation evolves, the more noticeable a shift in the type of moral attitudes that inform public perceptions and discourses is likely to become. The shift is from a solidaristic frame according to which “all of us” are in the “same boat” and must accordingly all pay for the benefits we all profit from, to a perception which understands the majority of low-risk people as practicing altruism in favor of a distinct high-risk group. To stick with the maritime metaphor, in the latter case the situation is interpreted as a majority of people watching a sinking ship from their place safely on shore, the passengers of which they are being called upon to rescue from their precarious condition. Unsurprisingly, members of the majority are quite likely to ask themselves and each other with increasing doubt if and why they should be obliged to undertake that rescue effort, something that they would do at considerable cost and risk to themselves.
As it comes to strategic policy choices, we may perhaps usefully apply a market analogy. As markets have distinct actors on their demand and supply sides, we can think of the virus as an agent “demanding” living cells that it can colonize, of which there is a smaller or greater “supply” available. If that makes sense as a model, we can define the objective of policy as reducing transactions in this “market” as far as possible, as it would similarly be the objective of anti-narcotics policies to dry up the market for illicit drugs. As in the latter case, policies can proceed by either focusing on the supply or the demand side (or both). Operating on the “supply” side, policy makers can adopt measures that result in (an approximation) to the condition of herd immunity after which the virus disappears due to the absence of available human cells needed for its reproduction (This assumes that the virus does not mutate so as to gain new access to cells that are not immune and that immunity lasts long enough. Otherwise, we would see repeated waves of infection, as we do in the case of influenza).The down side of this approach is that it takes many years before a sufficient level of collective immunity is reached while along the road the health system is to be kept intact. For NPI measures of social distancing etc. are designed to slow down the process that leads to such immunity in order to prevent the overburdening of the health system. The alternative approach focusing on the demand side of our “market” aims at the gradual reduction of the number of viruses seeking opportunities for reproduction. This strategy succeeds when the chains of infection are interrupted so that the virus cannot spread, or spreads more slowly so that there are continuously fewer viruses around. In this case, the reproduction rate R is less than 1, meaning that every person infected infects less than one further person. In order for this strategy to succeed, which also works through isolation and interruption of chains of infection, policy makers would have to make sure that territorial borders are tightened so that the decimated stock of viruses is not filled up by incoming infected persons and R remains = < 1. Here, the downside is not a problem of time (as with the supply side strategy), but a problem of space: the territory must be locked to virtually all outsiders. The demand side strategy seems hardly compatible with the EU’s Schengen open border regime as long as it is not equally adopted by all EU member states while external borders of the EU are effectively sealed so as to prevent virus “immigration”. But as long as there are vast differences in rates of corona-related deaths per one million inhabitants among member states (Belgium = 560, Slovakia = 3), the strongest reason for hope remains the development of a pharmaceutical pathway “out of” the corona crisis.
The further the pandemic progresses, and the more it produces a rising (and known) number of deaths, the less governmental policies will be able to fatalistically opt for inaction or denial and allow the “Tsunami in slow motion”, as a felicitous phrase has it, to run its course. Very soon, “doing nothing” is no longer feasible. It is exactly the slow motion that allows for time for intervention; “doing nothing” or acting “too late” becomes reprehensible. But the problem of governments is precisely that every policy act partly “endogenizes” the pandemic and its effects on health and all its other consequences, a factor which plays no role in the treatment of “sudden” and truly natural disasters (such as volcanic eruptions, earthquakes, or unpredicted tornados). The pandemic is then no longer just an exogenous fact of nature anymore; it becomes an internal occurrence as the damages it causes can and must be attributed to political actors and their belated or otherwise inadequate responses. After all, there was sufficient time to adopt the right and effective ones, people might say. For example if, at a later point in time it were to become evident that a lockdown had been lifted too early, political actors would likely be seen as co-guilty in the resulting deaths which are no longer unambiguously “caused” by the virus as an external shock. The longer the crisis lasts, the more damages is causes and suffering it inflicts will be attributed to policies adopted rather than the facts of nature which have just triggered the process.
Claus Offe | Berlin | 30 April 2020
* English version based on a draft translation by Malte Zumbansen and edited and expanded by the author.
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