Sunday, March 29, 2020

Beyond testing -- The central question for pandemic policy.

Two weeks of California lockdown have gone by and I do not see signs of plans being made for virus-safe reopening. The fight seems to be between lockdown and reopen -- with little thought to the only possible answer: reopen smart.

Today, my latest thoughts about how to reopen smart.

There is one goal to public health policy right now: Reducing the transmission rate, aka  reproduction number.

If one person gets it, how many does he or she pass it on to? If the transmission rate is over one, the virus grows exponentially. For example, if the transmission rate is 2, then we have 1000 cases this week, 2000 next week, 4000 the week after that, and so on. If the transmission rate under one, the pandemic ends. If the rate  is 0.5, then we have 1000 this week, 500 next week, 250 the week after that and so on.

(The second goal of health policy is to keep hospitals going so that those who do get it stay alive. That's what ventilators, masks and so on are about. As an economist, I'll focus on the first goal.)

So, the entire question is how to reduce the transmission rate at the least -- or at least reasonable, non-disastrous -- economic cost.

This simple framing could, I think, guide lots of policy.

We don't have to talk about lives vs. money. The lockdown is so disastrously inefficient, we can talk about more lives and less money.

We talk about the reproduction rate as if it is just a biological feature of the virus. That helps -- viruses that spread by airborne droplets pass on more easily. But most of the reproduction rate depends on human behavior -- and government policy.

Lockdown, quarantine, etc.  The point of a lockdown is to reduce the transmission rate. If you're at home, you can't get or give the virus. But as we are seeing a lockdown is an immensely costly policy. Lots of people are stuck at home and businesses failing that would not have spread the virus much had they been allowed out. We have to do better.

Fat tails. The reproduction rate is the average reproduction rate. But not everyone is average. Every interesting distribution has a fat tail.  In this lies a great danger and a great opportunity.

Suppose there are 100 people with a 0.5 reproduction rate, and 1 super-spreader with a 100 replication rate. The average reproduction rate is 1.5. Clearly, locking everyone down is wildly inefficient. It's much more important to find the 1 super-spreader and lock him or her down, or change the business or behavior that's causing the super-spreading.

This is exaggerated, but not far off the mark. I have not seen numbers on the distribution of reproduction rates across people, but it is a fair bet that it has an extremely fat tail. Most of us are washing our hands, social distancing, work in businesses that are shut down or are taking great steps to limit contact. And a few people and activities contribute to most of the spread.

This wide and fat-tailed dispersion is ignored in a lot of simulations I've seen. They take the average reproduction rate as the same for everyone. That's a big mistake.

The danger: we waste a huge amount of time and money moving you and me from a 0.5 reproduction rate to an 0.4 reproduction rate.

The opportunity: focus on the super-spreaders, and the super-spreading activities, and you bring down the reproduction rate at much lower cost.

Politicians sort of figured this out. They quickly closed bars, restaurants, and other gatherings where people are in close quarters breathing each others' air.

We're still opening and closing and not fixing enough. Food stores are open. But we aren't all wearing masks, the cashiers still don't have transparent barriers, and so on. Lots of businesses are closed that could easily open in ways that provide a reproduction rate under 1. Zero is not necessary. Under 1 is enough. Once it's under 1, it's not worth pushing harder -- go work on the super-spreaders

It's all about the probabilities. Lockdowns and extreme measures try to give zero chance of spreading  the virus. (Except that half the population is "essential," and from the looks of things not doing a very good job.)  All we need is to get the transmission rate under one. Activities with possible but very low transmission rates, and high economic benefits should go on. Don't separate to "essential" and "non-essential." Separate into "high likelihood of transmission" and "low likelihood of transmission."

Why are we not using masks everywhere? Sure, they're not perfect. Sure, an old hankerchief might only cut the chance of transmission by half. We're not all surgeons. Cutting by half is enough to stop the virus. 

Conversely, why did they close the state parks? Really? Just how dangerous is it to drive the dog to a hiking trail and stay 6 feet away from other people? Parks, ski areas, golf courses, all sorts of businesses that surely can be run with a reproduction rate far less than one are just shut down. I met a realtor on our dog walk yesterday. They're totally shut down. Just how hard is it to run a realty business with a 0.5 reproduction rate? One family in the house at a time, don't touch anything, an hour between showings, stay 6 feet from the realtor... But instead the whole business is just shut down.  

Testing Last week I got over-enthusiastic about testing as the key to virus-safe reopening.

Testing is just a high-tech approach to reducing the transmission rate at lower cost. If we could test everybody every morning and know the answer instantly, then we could send the healthy off to work, isolate the sick, and reduce transmission to zero at low economic cost.

But that's all it is -- one of many devices to lower the transmission rate more cheaply than a lockdown. There are many others.  Which is a good thing, seeing as we will not have a daily test for 325 million people for a long time.

Testing doesn't have to be perfect. For the question of deciding which sick patients should be isolated and treated, and which should not, yes, we need fast, accurate, individual tests. But for the public health question, imperfect testing is useful.

False positives are not really a problem. If 2% of the population has the virus, but 4% register positive, then 2% are sent home needlessly. That's a lot better than 100% sent home because we can't tell the 2% from the 98%.

False negatives are worse, but tests with false negatives help too. Suppose half of the people who have it test negative. If you give everyone a test and isolate those who test positive, then you cut the reproduction rate in half. Cutting the reproduction rate from 1.99 to 0.99 would be enough to stop the virus.

False negatives are also only a problem if the person has a high risk occupation or lifestyle. The reproduction rate of a Hoover  fellow is likely about 0.2. If the test misclassifies me, it makes little difference. Save the tests for the people and activities that must unavoidably have a very high reproduction rate.

Thermometers. There is a test that is simple and fast with lots of false positive and negatives. Why are we not asking every person to take their temperature every day, and self isolate if they have a fever? Why are we not using those infrared probes at the entrance to every food store, place of business and so forth? Sure quite a few covid-positive people with no fever will get through, and quite a few feverish people with something else will get sent home. But it cuts the probabilities at almost no cost.

Or a simple web form with symptoms? Fill this out, take your temperature, the web form says ok to work or stay home.

It's an indication of a very first-world attitude that public policy seems to be relying exclusively on DNA technology that didn't exist 10 years ago to provide us with perfect tests.

The goal is to let out people and activities with low reproductive rates, and keep at home those with high reproductive rates. Testing everyone with a perfect test and letting out those who pass is a magic bullet. But it's not the only bullet, and it's a bullet we don't have right now. There are lots of simpler low tech ways to let out people and activities who are likely to have low reproductive rates, and keep home those who are likely to have high reproductive rates. We don't have to wait for snazzy technology.

Economics So what'w the answer? I think it remains the same, and the one that our public policies seem not to be working on: reopen safely.  Phrasing it in terms of reproduction rate might help. For each business, how are you going to open in such a way that the reproduction rate among your customers and employees is less than one? Disinfect premieres every day, take the temperature of everyone coming in, everyone wears masks, move workstations six feet away, rotate workers from home, add barriers... Is that enough so that a sick person coming in infects no more than one other person? Good enough.

There must be a safe reopening plan. We're not going to get nationwide testing of well people any time soon,

Herd immunity The optimist case for this virus right now centers on the idea that many more people have got it than we think, and therefore are immune going forward. If half the people already have it, then this cuts the transmission rate in half. Again, everything is about the transmission rate.

While I hope this is the case, it will mean we dodged a bullet and just got immensely lucky. The virus is out there that makes everyone sick and kills 10%.

Good links

Larry Kotlikoff thinks through the practicalities of group testing, a way to cut the costs of testing by orders of magnitude.

Health and Pandemics working group on pandemic economics

Jim Stock's blog. Jim's March 23 paper is excellent. Jim also clarifies that policy is about one and only one thing: reducing the average transmission rate. Jim thinks about dynamics, making the point that reducing the rate early is better than reducing it late, and worth paying more to do so,

Becker Friedman blog. Good short fact-laden posts.


Thanks to commenter "Fat Man," Jonathan Kay at Quillette writes on the skewed distribution of the transmission rate, and the fact that most models take it as a single number.
In a 2016 paper, South Korean doctor Byung Chul Chun noted that the MERS outbreak could be summarized as:
"an explosive epidemic by infrequent super-spreaders. The number of secondary cases in the transmission tree was extremely skewed. Among 186 confirmed cases, 166 cases (89.2%) did not lead to any secondary cases, but 5 (2.7%) super-spreaders lead to 154 secondary cases. The imported index case [i.e. original case] was a super-spreader who transmitted the MERS virus to 28 people (referred to as secondary cases), and 3 of these secondary cases became super-spreaders who infected 84, 23 and 7 people, respectively. Eighty-four secondary cases resulting from a single case is one of the largest numbers observed in a SSE since the SARS outbreak in Prince of Wales Hospital in Hong Kong. None of the super-spreaders in the MERS outbreak in Korea was a healthcare worker."...
... June, 2020 Centers for Disease Control and Prevention (CDC) report, Identifying and Interrupting Superspreading Events—Implications for Control of Severe Acute Respiratory Syndrome Coronavirus 2, by Thomas R. Frieden and Christopher T. Lee. Echoing points made by Dr. Chun and others, the authors note, “SSEs highlight a major limitation of the concept of R0,” since R0, being a mean or median value “does not capture the heterogeneity of transmission among infected persons.”...
From Seattle to South Korea, many of the biggest outbreaks were fuelled by a small handful of very sick, highly symptomatic people who drifted along for days before their condition was correctly treated and isolated. (In South Korea, some have noted, the problem was exacerbated by patients who went “doctor shopping,” spreading their germs in many different clinics.)...
While we are at it, we need to stop wasting resources on pointless measures such as closing remote parks and natural reserves, where few people come close to one another anyway. In an especially important section of the aforementioned CDC report, the authors note that even COVID-19 super-spreaders can’t seem to infect people effectively in open spaces: “Rapid person-to-person transmission of COVID-19 appears likely to have occurred in healthcare settings, on a cruise ship, and in a church. In a study of 110 case-patients from 11 clusters in Japan, all clusters were associated with closed environments, including fitness centers, shared eating environments, and hospitals, [where] the odds for transmission from a primary case-patient were 18.7 times higher than in open-air environments.” These closed environments represent the sort of scenario we need to target—not British couples out on a jaunt to Sugar Loaf, Pen-y-Fan and other rustic destinations...
Even long before COVID-19 was a thing, infectious-disease experts such as James Lloyd-Smith were arguing that “the distribution of individual infectiousness around R0 is often highly skewed”; that approaches accounting for super-spreaders do a better job modelling the sudden cluster-based boom-and-bust quality of many diseases; and, crucially for today’s policymakers, that such analyses show how, in these cases, “individual-specific control measures outperform population-wide measures.”

This piece goes half way, I think, to the right conclusion. Reproductive rate is not a low number plus a few super spreaders. It is a distribution with a very fat tail. The report seems to personalize the super spreaders as particularly ill behaved people. They are more likely normal people who participated in a particularly poorly structured activity, like the famous South Korean church.

Our first goal should be to stop that fat tail.

Click the "pandemic" link below to see all blog posts in this series.


  1. "COVID-19 Science Update for March 27th: Super-Spreaders and the Need for New Prediction Models" by Jonathan Kay

  2. Thanks for mentioning thermometers. Imperfect information is better than no information.

  3. "The virus is most contagious when people are symptomatic; while spread may be possible before symptoms appear, this risk is low." - Wikipedia.

    Given the above, testing symptoms (ie: coughing, fever) and leaning toward false positives, would reduce the growth dramatically while enabling those without symptoms to continue working.

    Thus, steep penalties for employers and employees who are working sick would probably eliminate this entirely. And, the US may as well just keep penalties in place permanently: it should be illegal to be in public with a fever or cough.

  4. My instinct* is that we should not pursue a "smart reopening." And the reason is NOT the whole "how dare you trade lives for money?!?!" silliness one often sees: long/severe recessions kill lots of people too, it's just harder to measure.

    My guess* is that shortening the duration of the outbreak, and giving people some ability to plan around its end date, is far more critical than lessening total severity. Even the smart reopening you speak of will increase the duration of the outbreak somewhat, and make it harder to predict when the outbreak will end.

    If people don't know when this will end they will eventually freeze spending, liquidate their 401ks and hoard food. If people instead (believe) they know the end date, they'll instead use their time away from work to plan all the fun stuff they will do once this ends. Their cash will remain in the markets, they will continue to shop online, and spending composition will be as normal as possible given the circumstances. I think that's the better course.

    *I won't pretend to know the correct solution, no one does, these are just my guesses based on personal experience/anecdote.

    1. Even without a "smart reopening" you don't know when this will end. Even with a smart reopening you could scale back the precautions in place as death numbers go down in different areas.

  5. John's comments on this have been great, and are much appreciated.

    I want to jump in with one side issue that has baffled me for years.
    (I am not an economist, I was a history major)

    Economists will save that saving a life has positive value, sometimes in the noted in one of the blogs that John cited,

    "benefits we compute are in the trillions of dollars because they capture the total value Americans place on remaining alive: not just the income they earn, but also the value they place on leisure, spending time with friends and family, and all other activities"

    I just do not get it. I am 72 years old. If we add ten years to my life, I will receive another $400,000 in Social Security and Medicare benefits. (At age 72, the amounts I have already received may equal what I paid in.)

    From age 72 to 82 if you save my life, I sure as heck will not be paying $400,000 in taxes. I am not well off.

    So by my rustic standards, saving my life is very costly. Counting the value which I put on my life is gibberish to me.

    I do not mind being proven wrong, if anyone cares to do so.

    1. I'm not sure how economists estimate it. I would do it like this: "ask" a 20 years old how much they would be willing to spend to add one year to their life when they are 80. It's probably a large value, but they would not be willing to live the next 60 years as poors to add one more year to their life. Of course, asking doesn't work, you have to see their preferences as revealed by life choices.

    2. Bob,
      You are technically correct about the specific situation you describe. Though it is not clear whether or not you are correct when one takes into account the average of the possible situations for people in the age range you highlighted.

      Some alternate scenarios:

      An older individual in the 72+ range that has a large nest egg which they acquired through judicious investment. Should they live another ten years they can achieve at least market returns of 6% annual and perhaps more. If they die the capital would be divided between let fiscally responsible parities. As the size of the endowment increases at some point the capital gain from good management will start to outweigh the dead weight loss of the 72+ persons body + home + SS payment.

      Some 72 year olds are still working. some are even running large companies (oracle of Omaha anyone). Same situation if the follow-on CEO is not as sharp at management as whoever the successor is.

      So in the individual case yes you might be a dead-weight loss to the rest of us (a taker?). But it is not clear to me what happens if you average the opportunity cost of all 72+ individuals out. How many dead-beet boomers can one Warren Buffet cancel out? I just don't know but I hope the experts already did the work and didn't fat finger it when the shoved the numbers into the spreadsheet.

      Cards on the table I'm 31 and don't like unemployed folks (that's what it's called when you aren't working). but I will give them a pass because I live in a society. Maybe the boomers ran away with the piggy bank but I will get up everyday and keep the machines running, even if it kills me. because that's what working people do. Rain sleet snow shine it's not over till the robots come for the very last one of us!

  6. John, the reason to close national parks is to protect folks like us in small towns that give access to those parks and have limited medical facilities. Sure, Yellowstone is empty, but there are those visitors going to shop, stay, etc?

    Otherwise, your ideas are great. We need more thinking about this stuff.

    1. giving folks access to a park is not a high risk, or should not be a high risk endeavor. Get a grip

    2. In Wisconsin we just eliminated the fees and the people who collect them at state parks. No risks of infection and no symbolic “Closing the WWII Memorial” on the mall as the petty previous POTUS did. Businesses would still be closed so only campers and those that live nearby would visit. It might be the experience of a lifetime for someone on furlough.

  7. I've been reading you for several years now. Most the econo-math posts are way over my head, but I enjoy the policy critiques and comments. The recent ones have been particularly good.

    "The report seems to personalize the super spreaders as particularly ill behaved people". With roughly half the population below average intelligence and many of them living in poor conditions and following poor role models, behaviours can be hard to change. The spit-in-a-bucket arrangement that you presented last week seems like the best approach, but even that misses the unemployed and self-employed. Eventually all the idiots will either be immune or die off. The rest of us just have to stay out of their way until then.

  8. First use social distancing (until testing can catch up, and we are no-where close), and then think about how to 'smartly' reopen, when you bent the curve sufficiently. Otherwise, you could kill the positive effect (having gained time by using the highly intrusive shut-down method):

    "Pandemics Depress the Economy, Public Health Interventions Do Not: Evidence from the 1918 Flu"

    45 Pages Posted: 26 Mar 2020 Last revised: 27 Mar 2020

    See all articles by Sergio Correia
    Sergio Correia

    Board of Governors of the Federal Reserve System

    Stephan Luck

    Federal Reserve Bank of New York

    Emil Verner

    Massachusetts Institute of Technology (MIT) - Sloan School of Management

    Date Written: March 26, 2020


    What are the economic consequences of an influenza pandemic? And given the pandemic, what are the economic costs and benefits of non-pharmaceutical interventions (NPI)? Using geographic variation in mortality during the 1918 Flu Pandemic in the U.S., we find that more exposed areas experience a sharp and persistent decline in economic activity. The estimates imply that the pandemic reduced manufacturing output by 18%. The downturn is driven by both supply and demand-side channels. Further, building on findings from the epidemiology literature establishing that NPIs decrease influenza mortality, we use variation in the timing and intensity of NPIs across U.S. cities to study their economic effects. We find that cities that intervened earlier and more aggressively do not perform worse and, if anything, grow faster after the pandemic is over. Our findings thus indicate that NPIs not only lower mortality; they also mitigate the adverse economic consequences of a pandemic.

    Keywords: 1918 Flu Pandemic, non-pharmaceutical interventions (NPI), real economy

  9. "Super-spreading" is entirely behavioral, right? There's nothing biologically pre-disposing someone to spread more than another, outside of their baseline viral load?

    It makes me somewhat more pessimistic, relying on a behavioral change, rather than finding something we can medicate or isolate to lower transmission rate. I travel a lot for work and the hygeine habits of most people are, frankly, disgusting. I see people who are the worst offenders being some of the last to finally decide to cough in their elbow, wash hands, etc.

  10. LA Times just published a story about a choir that decided to have a rehearsal on March 10th. 60 people came. Since then 45 have been diagnosed with COVID-19 or ill with the symptoms, and two are dead. Interestingly, Jamie Lllyd-Smith, a UCLA infectious disease researcher, called it a "super-spreading event."

  11. I believe the lawyers are driving a lot of decisions. Not many want the risk of expensive lawsuits because they didn't follow the herd.

  12. I agree that testing is not the only hope and maybe not even our best hope for getting back to normal in time to make this nothing more than a really bad recession. He's also right in pointing out that tests with significant false negatives are still valuable. Romer's simulations indicate that even an 80% false negative rate is still helpful in reducing R0. The only thing I'd add to Romer's numbers is that widespread testing has to be followed by self-quarantine and some people are not going to comply--especially people who have few symptoms. But if Romer's numbers are right, that's not a deal-breaker. A non-compliant true positive is no different than a false negative. In other words, we can have bad tests and good people or good tests and bad people.

  13. Fat tails have been ignored across markets repeatedly. For years I traded in the capital markets and managed risk for Merrill Lynch and a number of hedge funds. Because I didn't know when disasters would occur, I did know they happened faster than one could imagine. living in the heavy left tail of market returns, I always bought insurance knowing it was a bad trade until it wasn't. There will be pandemics, Wars, Nuclear accidents and earthquakes. Manage the risk now before it's to late.

  14. My impression is that much of the data used are approximations, even known under counting. How many people are walking around self-immune, or partially so from prior vaccines, would be interesting. But like most data being used now, they are 'iffie.' The one data point that seems reliable are deaths. And yet, I wonder what percentage of these deaths are not from the virus, but from preconditions, lumped into the viral death category. Deaths due to virus infection are likely inflated. Lastly, I do accept that the virus contributes to the acceleration death rates, but I believe it is a fraction...a big fraction....comparatively speaking, to the ups and downs we are attributing to the virus, and if so, the justification for the expenditures, and lost production that decelerating most human contact, and the economy, has, and will, produce.

  15. It is interesting that what you seem to recommend seems to be very close to what Taiwan has been doing (temperature measurements everywhere, not a lot of RT-PCR test, mask wearing in building, using low-tech physical separation (in schools when kids eat), isolation. Even better, it worked!
    None of the good links seems to point what one one can learn from countries that have managed to get things under control without lockdown.

  16. Thanks for writing this up and sharing it. It makes a lot of great points and has affected my thinking on strategies to fight covid19.

    At multiple points in the post, you talk about cutting the transmission rate (R0) in half is enough. I remember seeing some estimates that R0 has been in the range of 4-6 in multiple Western countries (before drastic measures). Does this change your stance on anything?


  17. Could we not just seaquester elderly smokers and go back to normal?

    As long as we have a naive population in relation to a novel virus, how can we truly exit a lockdown?

    By the way, in Thailand, workers who have been tossed off the job due to lockdowns are saying, "We are not going to die of Covid-19. We will die of hunger."

    Having public health officials make economic policy....

  18. John,
    practicality and enforcement should be considered. Can we sell some reasonable partial opening measures so that ppl actly get serious about following their spirit and make them work? stay at home is at least blunt and easy to understand. Given we're so free we aren't willing to enforce anything, is it really wise to rely on ppl's conscientiousness for something so local and nuanced, while so far they don't even bother to wear masks or work on those simple distancing measures in businesses you mention? Mb it is about good leadership and ppl can be sold, that said again obvsly we aren't gonna get that leadership, making case for trickier policies harder.

    Mb I'm with you in that the best response would involve lots of smart local decision making re ways to make business safe, and govt's blunt response might've been in the way there. Yet for me the hard step to that dream is not removing govt, but motivating and leading ppl to act.

  19. John, you might want to peruse the large literature on behavioral responses during epidemics, e.g.,

  20. There are but a very small tribe of spatial epidemiologists (using space-time diffusion modeling). Their mathematical consensus is spatial R0 does not behave like the normal R0 = 1 as in temporal models, and can be much less than 1 and still spread like >1. Backward bifurcation, spatial mixing, hysteresis etc. can complicate the non-linear dynamics. In fact R0 close to ZERO shows pandemicity in networks that entail explosive percolation.

  21. The province of British Columbia, Canada, has published its COVID-19 cumulative cases, active cases, recovered cases and deaths logged since January 28th, 2020. The data include demographic distribution of population, cases and deaths by age bracket. For the analytically-minded, the information will likely be of some interest. A comparative study of log(cases) vs elapsed time since cumulative cases hit 100 for several european and Canadian reporting jurisdictions and Washington state may be of interest.

    Article appears here:

  22. I am very impressed by your analysis that makes a very good link between epidemiology and economics. It supplements and illustrates well the constrained maximization problem for public policy proposed by Eric Budish: Maxizing Social Welfare subject to (1) Technological Constraints, (2) Incentive Constraints, and R < 1: Reduce the Covid-19 Average Transmission Rate to Below 1.

  23. Greatly appreciate your article as it showcases many practical truths in how to better handle the situation. Tragedy is that measures proven to work in S Korea and densely populated Singapore ( 1,049 cases to date with population of almost 6 million living in high-rise New York City apartments) are unlikely to be implemented effectively here. Temperature taking is routine in Singapore and self-quarantines are backed by huge fines. We are, for example, still elevating whether or not to clamp down on domestic travel between states for non-commercial purposes! My fear is that at this rate, all 50 states will be infected due to "imported" cases from hot spots.

  24. "Our first goal should be to stop that fat tail." - J. Cochrane. Bravo! Indeed, is that not the first goal of a "lock-down" stricture? To reduce the average contact time and the exposure of the population to the disease pathogen, one would want to confine the population to their dwellings to the maximumm extent practicable.

    The first cost is undoubtedly very high as evidenced by the impact on the economic activity of the nation. But, is it not also likely, as we are now seeing with the strikes by "essential" workers at organizations such as who fear for their own health outcomes if they continue to work at jobs without adequate protective measures in place, that they will simply stop working altogether and the economic outcome would be the same as if no "lock-down" were imposed?

    To "re-open" the economy "partially" "safely", one needs to have in place measures which ensure that those workers who return to their places of employment and those customers of the those places of employment who recommence their economic transactions with those businesses can do so safely without fear of contracting the disease and subsequently an outcome more adverse than that from refraining from engaging in those activities.

    Would an economist be prepared to recommend a course of action so fraught with risk if that economist were held personally liable for his/her recommendations (as an professional engineer of record is held to be liable in his/her personal capacity for the design of a structure or building in this country)? I rather doubt that any economist worth his/her salt would be prepared to take on that risk.


Comments are welcome. Keep it short, polite, and on topic.

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