And this: The world probably lost about 13 million people to various ailments in the past three months, and just over 11,000 to the coronavirus. Is it a reasonable trade-off to shut down most of the economy to prevent more covid-19 infections? Are we using a bazooka to kill a flea?
But the truth is, the time hasn’t yet come to finely measure trade-offs.
The appropriate analogy for our moment is Pearl Harbor. As bombs fell on Hawaii, life went on almost normally in the rest of the United States. But the reality was clear. The country needed to transition to a war footing.
Today, we, too need to be on a war footing. As was the case in 1941, our war is defensive and therefore just. Our job for the next six weeks is to save our health-care system in order to save a functioning society. To do this, we undertake a process of societal triage that puts us in an effective position to fight the coronavirus. How? We transition our economy from travel, culture and restaurant dining to investments in medical and sanitation supplies and services — a rapid, wrenching disruption requiring government funding if we are going to achieve the transition without economic collapse. We sacrifice in-person education and business transactions to try to control the rate of transmission. We do these things as a matter of generalized social triage to save the health system.
Why do we have to give so much on behalf of a system? Why not focus just on saving lives?
In every society with a well-ordered government, that government has responsibility for the well-being of its people. A country’s public health infrastructure — whether that consists of public systems or public-private hybrids — is a national asset for which the government is responsible, just as it is responsible for a national defense system. In the modern world, when health systems collapse, we can expect societies too to collapse, in the same way that if a military collapsed, we would understand that the society was imploding.
The fight against the virus is aimed, yes, at saving individual lives, but also aimed at saving our medical infrastructure as such — because it is necessary to preserving our ability to function as a society. In other words, we are not engaged in an enterprise of balancing some people’s current lives against other people’s future well-being. We are engaged in the enterprise of figuring out how to ensure that this society can, in the first place, preserve the very institutions whose job it is to heal, educate and employ.
Our choices at this point are existential, not yet about fine-grained trade-offs. We will have the luxury of framing our choices as a question of balance when we know that our fundamental institutional structure has been re-secured.
How do we know the risk to our health system is this severe? Here are the core facts:
- Modeling by the Centers for Disease Control and Prevention suggests that, “without mitigation, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes novel coronavirus disease 2019 (COVID-19), could infect more than 60 percent ... of the U.S. population.”
- About 4.4 percent of all known cases of infection have required hospitalization; of those patients, 30 percent needed intensive care, according to a March 16 report by researchers in London.
- Care for hospitalized covid-19 patients commonly requires weeks of treatment.
- Medical and support staff for all those patients must use personal protective equipment and engage in complex decontamination procedures.
- Evidence so far suggests that the viability of the virus is unlikely to be significantly decreased by warmer weather.
- We already have shortages of testing kits, high-filtration N-95 ventilators and intensive-care beds.
- There are as yet no anti-viral treatments, though some potential therapies are beginning to emerge. In a best-case scenario, the timetable for developing a vaccine is 12-18 months .
- The fatality rate from best estimates is in a range of 1 to 2 percent of infected persons; that sounds like a small number, but if 60 percent of the population were infected, that would mean about 2 million deaths.
The inevitable conclusion: If we let the disease simply proceed unchecked, the number of cases will swamp our health-care infrastructure. This would in turn destabilize our political institutions. The death toll itself would have a significant psycho-social impact that would also be destabilizing. Regrettably, there is no way to change the trajectory of the disease other than through the social distancing we are undertaking.
The threats of war notably include loss of life, yes, but also instability of economy and society, degradation of standards of justice and disintegration of the political institutions in the polity under attack. The same threats pertain now. That is why we need to understand ourselves as on a war footing and our job as not cost-benefit balancing but existential decision-making about arranging and triaging our activities and resources to maximize our ability to fend off a fundamental threat.
In the face of surprise attack by an armed enemy, societies understand this and enter into a process of triage to ensure the society as a whole is ready to wage war. That is the stage we are in now. We are triaging the parts of the economy we don’t need for this fight. We are triaging kids’ time in school so that we can deliver back to them a stable society that can provide school. As we triage in this way, we also need to recognize that, in the language of just-war theory, fighting justly requires protecting the innocent and vulnerable, civilians and non-combatants.
Now, too, as in a defensive war, the goal is to defeat the adversary with minimal loss of life and minimal damage to the material supports of a healthy economy and society. The fight must be waged with a view to laying a foundation for a transition back to a peacetime setting and fully renewed political and social institutions. In other words, the goal is not to defeat the adversary at any cost but to preserve society, including preserving it as the kind of society it is.
In the case of the United States, this means that efforts must always have in view not only protecting American lives but also American constitutional democracy and its cultural supports, including sturdy standards for ethical action and robust commitments to justice. Protecting the vulnerable is one of the first requirements of fighting a war justly.
In addition to accepting the rigorous demands of aggressive social distancing, then, we need to invest publicly and privately in the re-composition of the economy in support of the effort to fight the virus; we need to invest in sustaining output in the economy; we need to find alternative ways of educating homebound children, including through the mail, as well as digitally; we need to find ways of feeding children who received their nourishment at school; we need to secure mail-in and absentee ballots for comprehensive use over the next 12 months; we need to ensure that states use their quarantine authorities in ways that align with the requirements of civil liberties; and we need to include incarcerated, homeless, nursing home and undocumented populations in our efforts to protect the vulnerable. The effort to control the spread of the virus will have to be a whole-society undertaking.
My colleagues and I offer more detail on each of these choices in the white paper we published today, “Securing Justice, Health and Democracy against the COVID-19 Threat.”
Insofar as questions about how to balance one set of costs against another depend on the existence of a functioning society, our first effort — over the next six weeks — should be to focus simply on saving that functioning society while protecting the most vulnerable as we do. If we work hard enough and fast enough, as if in response to a surprise attack, we ought to then be able to revisit our first-round choices and decisions — and again six weeks thereafter and so on. As we walk through that process, we will also learn more about this specific adversary, what it means to fight it and also what it will mean to live with it in an ongoing way once it is under control.
We can hope for effective anti-viral therapies and a vaccine and invest in their production, but we have to plan for a world without those. That means engaging now in a sustained process of societal triage as we put ourselves on the equivalent of a war-time footing.