How FDA and CDC made COVID-19 crisis worse

Hawaii’s economy has been suffering enormously because of the coronavirus lockdown, and much of the blame can be traced to the federal Food and Drug Administration and Centers for Disease Control and Prevention.

That was the view of Jacob Sullum, a nationally syndicated columnist whose writings appear every Saturday in the Honolulu Star-Advertiser, who was the special guest for a webinar on Tuesday, May 5, sponsored by the Grassroot Institute of Hawaii.

Sullum wrote in one of his recent columns, that the failure of the FDA and CDC to implement early and widespread testing “left politicians scrambling to avoid a hospital crisis by imposing broad business closure and stay-at-home orders.” 

“It foreclosed,” he said, “the possibility of a more proactive and targeted approach, focused on identifying carriers, tracing their contacts, and protecting the public through isolation and quarantines.”

Sullum’s weekly column, distributed by Creators Syndicate, is carried by not only the Honolulu Star-Advertiser but also the New York Post, the Chicago Sun-Times and other newspapers across the country. His work also has appeared in The Wall Street Journal, USA Today, The New York Times, the Los Angeles Times, the San Francisco Chronicle, National Review, and many other publications. He also a senior editor of Reason magazine and blogs about drug policy for Forbes.

At the end of his presentation, Sullum answered questions from the audience. Moderator for the hourlong Hawaii webinar was Keli‘i Akina, Ph.D., institute president.

Complete transcript of the webinar:

Keli‘i Akina: Well, aloha and welcome to Grassroot Institute of Hawaii. I’m Keli‘i Akina, President and CEO, and this is our ongoing seminar series. I’m just so delighted that all of you have shown up. We’ve got a great audience today and a great program today. It’s May 5th, 2020, which means Cinco de Mayo, so happy Cinco de Mayo. Even as we speak now, we have our governor addressing the issue of the coronavirus response and he’s updating his proclamations.

One of the things he’s doing is opening up certain venues, such as shopping malls and retailers, although you can’t sell food in the food courts. Nonfood agricultural businesses including florists, observatories — astronomical ones — pet grooming services, healthcare and social assistance services, nonprofits and wholesale businesses.

I want to take my hat off to him for getting the ball rolling. It’s not everything yet. For example, restaurants aren’t open for sit-down services nor childcare services, but it looks like the governor and our government in Hawaii are responding to a large chorus of voices that are saying, “It’s time to get back to work.” Now, we don’t say throw caution to the wind. It’s important for the government to continue to protect the public health, but one thing is certain: The longer we stay shutdown as an economy, the longer we do long-term damage that may not be reversible, especially here in the islands. 

Now, we’ve got some good news for you. As of last Wednesday, Grassroot Institute launched a petition drive and has sent letters with this information to the governor. The basic message of the petition is “Let Hawaii work,” and you can still sign on to that. As of this morning, more than 5,000 people have signed on and said to the governor, “Let Hawaii work.” Go to lethawaiiwork.com. 

Just a quick announcement before we get to our program today. Our next webinar takes place on Tuesday, May the 12th. One week from now, at 12 o’clock, noon. Our guest is going to be Steven Greenhut, who’s a senior fellow at R Street, a columnist at the Orange County Register, and he used to be with the San Diego Union-Tribune. He’s going to take a look at our state’s economy and answer the question: Could Hawaii go bankrupt, especially in light of what has happened with the coronavirus response? 

Well, now to today’s topic. I’ve been looking forward to this quite a bit: How the CDC and FDA wrecked our economy. Now, that’s a question. Did that happen? But there is an expert who believes that that’s exactly what took place.

Jacob Sullum is our guest today. He’s a nationally syndicated columnist whose writings appear every Saturday here in the Honolulu Star-Advertiser and across the country. Sullum is also a senior editor of Reason Magazine, he’s written in New York Times, Wall Street Journal, and other national venues. Sullum wrote in one of his recent columns that the failure of the CDC and FDA to implement early and wide testing, “left politicians scrambling to avoid a hospital crisis by imposing broad business closures and stay-at-home orders.”

He continues, “It foreclosed the possibility of a more proactive and targeted approach focused on identifying carriers, tracing their contacts, and protecting the public through isolation and quarantines.” 

Now, our purpose here is not to place blame, but to analyze so that we can improve our response to the coronavirus situation and to prepare for the future.

During the webinar, Sullum will discuss the policy blunders, in particular that led to the coronavirus lockdowns, and what can be done to avoid them in the future. I’m so delighted to have a fellow member of the think tank community joining us today. Please welcome him, live from Dallas, Texas — Jacob Sullum. Jacob, aloha. Welcome to Hawaii.

Jacob Sullum: Thank you.

Akina: Tell me a little bit about how you’re hunkering down and what the weather is like over there in Dallas.

Sullum: Well, I’ve been working at home since the mid-’90s, so there hasn’t been much change in my work routine. The weather is starting to get hot, as it tends to do this time of the year in Dallas, which should be a good thing in terms of the epidemic. It gets into the hundreds in the summer, or high-90s at least. It goes all the way down to a refreshing high-80s at night. So that’s probably good news as far as health concerns go.

Akina: Well, the hot weather is according to some theories a good thing for dealing with coronavirus.

Sullum: Right. 

Akina: Before we get started today and jump into your presentation, tell us a little bit about how you got involved with Reason Magazine and how you became a columnist.

Sullum: Well, I’ve been working for Reason on and off since the late ’80s. Before that, I was a newspaper reporter, and somewhere in between there, I was an editor at National Review. I went back to work for Reason when I started writing my first book, and the column started in the late ’90s.

Akina: Very good. Well, we’re looking forward to your presentation. I want to invite everyone to pay close attention and ask any questions and make any comments you want. Do that online, and at the end of the presentation, which is in about 20 minutes, Joe Kent will moderate your questions and your answers. 

Now, to Jacob Sullum. It’s all yours for the next 20 minutes, Jacob. Go ahead.

Sullum: All right, thank you. I wanted to talk a bit about the testing situation in the United States, how it came about, and why it matters in terms of our knowledge of the epidemic and the way the government has responded to it. 

Just to remind you of some important dates, the initial outbreak of COVID-19 was reported in Wuhan, China, back in late December. The first case in the United States was reported Jan. 20 and that was in Snohomish County, Washington. It involved somebody who had returned recently from Wuhan. 

But, more recently, public health officials have confirmed that a woman in Santa Clara County, California, died on Feb. 6 from COVID-19, and she did not seem to have any kind of international travel, no direct contact with anybody who had traveled internationally. So it looks like she got the disease through local transmission, which means that COVID-19, the virus, was spreading through Northern California, the San Francisco Bay Area, as early as mid-January.

New York City, which has been the hardest-hit jurisdiction in the country, reported their first case March 1. But at that point, according to modeling by people who looked at the epidemic there, they may already have had more than 10,000 cases even though they had only reported one confirmed case. It’s in this context you have to understand what happened in terms of testing, which was a policy that was shaped both by the CDC and the FDA. 

The CDC initially decided not to use the virus test that was being distributed to other countries by the World Health Organization. Instead, they decided to develop their own test. They felt that it would be more precise, that they would be able to validate it internally and that that would be a better approach — which might have been fine, except that it didn’t turn out so well. Initially, the CDC was doing all the testing for the whole country (by) itself. You had to send samples to the CDC for them to be screened.

It finally started shipping its tests to state laboratories, public laboratories, in early February, and it turned out those tests were defective. It looks like they were defective because they had been actually contaminated by virus particles within the CDC laboratory. So those tests were no good, and this issue was not really resolved until late February, when the FDA told state laboratories that they could begin using their own tests to do screening. That’s basically a month lost just due to that delay.

Another example of what the CDC did that was problematic was they told the researcher at the University of Washington, Helen Chu, that she could not use samples that had been collected as part of a flu study to try to see what the progress of COVID-19 was in Washington State. There were several reasons for that. One was the samples were collected for one purpose, and you could not ethically use them for a different purpose. Another was, the labs she was using were primarily research labs, not clinical labs. The third thing was that she was using her own test, which had not been FDA-approved. Now, these all may be reasonable or not rules in general, but certainly, given the public health emergency, it seems like they could have and should have been suspended. 

She went ahead and tested these samples anyway after getting resistance from the CDC, and she discovered that a local teenager had been infected through local transmission by Feb. 25 or so. That’s a big deal because that shows that it was already spreading through the community at that point. The CDC told her to stop testing the samples that had already been collected for that study.

Meanwhile, researchers around the country are developing their own virus tests, none of which had been government-approved, and they had to wait for the FDA to give them what was called “emergency-use authorization” — which sounds like it would be pretty quick in light of the emergency but in fact caused delays of weeks or a month or longer. 

I’ll just give you a couple of examples of that. The clinical lab in Stanford University developed a test by February, but they were so daunted by the regulatory requirements that they initially didn’t even seek approval. They did not begin testing until early March, which is when the FDA relaxed it’s rules. So that again is a lost month or so when they could have been doing testing. 

Companies ran into similar problems when they would confer with the FDA. One French company had developed a test, and they started talking to the FDA in early February. They didn’t get approval until March 24th.  

Meanwhile, as you have the shortage that’s exacerbated by the failure to approve new tests, the CDC is setting unreasonably narrow criteria for testing. 

Initially they’re saying only people who came from Wuhan, traveled from Wuhan, … and had symptoms consistent with the disease (should be tested), or people who were in close contact with people who seemed to have the disease. That was in January, when the disease is already spreading. Feb. 1, they said not just (people who traveled from) Wuhan, (they) could also be people from Hubei Province generally, or anywhere in China if they had symptoms severe enough to require hospitalization.

The end of February, (the CDC) started adding travelers from other countries like Italy, Iran and Japan and South Korea, as well as people who had been hospitalized regardless of their travel history. 

Then in early March, they began to say doctors should decide who should be tested. They added (about a week later) a recommendation that people with a pre-existing condition should have priority … and they currently are still saying, the CDC is still saying, not everyone needs to be tested.

Symptoms are typically mild, you can recover at home, and even if you have these symptoms and you think you have the disease, you don’t necessarily have to be tested — which is pretty remarkable at this stage of the epidemic, when you really want to try to get a handle on the prevalence of the disease. (The CDC) notes that although supplies of tests are increasing, it may still be difficult to find a place to get tested. 

As of March 7, which is nearly two months after the virus apparently was spreading in Northern California, the U.S. had done a total of only around 4,000 COVID-19 tests.

A month later, that number had risen all the way to two million, so that looks like a pretty big jump. As of this afternoon, the U.S. had done about 7.3 million tests, which sounds like a lot, but it comes out to about 1,800 tests per 100,000 people. If you assume that it’s one test per person, which isn’t necessarily true — but let’s be generous — that still means less than 2% of the U.S. population has been tested.

If you look at Iceland, which is a country that emphasized early and wide testing, they have tested more than 50,000 samples, that’s about 15,000 tests per 100,000 people, something like 15% of its population. Huge difference. 

You might ask, we have millions of tests now, how many do we actually need? That depends who you ask, but just to give you a couple of examples to get an idea: A study by Rockefeller Foundation said that in order to do proper surveillance of the epidemic, we need over the short term to triple the number of (weekly) tests from about one million to about three million, and over the longer term, that we need to have 30 million tests a week. We need to have 30 million tests a week, or about 30 times the current number, and actually four times the total number of tests that have been conducted so far.

Another study by researchers at Harvard looked more specifically at individual states and said, “What level of testing do you need to have for us to be comfortable start to lift lockdowns, and where we can be confident that we can monitor things?” They found that most states, 31 states at the time, were not meeting those standards. In other words, they did not have enough testing capacity to proceed with lifting lockdowns and be confident that they could monitor how things were working out.

As a result of this test shortage, which was government-aggravated if not government-created, there’s still a lot that we don’t know about the virus or about the epidemic within the United States. A few questions that we don’t really know the answers to: How prevalent is the virus? How many Americans have been infected by it?

I’ll give you several different estimates that come from antibody studies, which have certain methodological issues, which I’ll get into briefly. But just to give you a sense, in San Miguel County, Colorado, which is a rural county, a sparse population, the antibody test suggests somewhere between 0.5% and 1.5% of people have been infected. That depends on whether you include ambiguous results or not. A study in Santa Clara County estimated about 3% of the population had been infected by early April. (In) Los Angeles County, an antibody study said there was about 4% prevalence.

A more recent study in Miami-Dade County said about 6% of local residents had been infected, and a study in New York City estimated the prevalence there was 21%. It’s much higher than these other studies, but something that you might expect given the very high population density in New York. 

Now, just a couple of major potential problems with these studies is sampling bias. You want to make sure your sample is representative, and these different studies have different issues in terms of the representativeness of their samples. The other issue is false positives.

You want to have a test that has very high specificity, meaning that when it says the antibodies are present, you either have 100% confidence that’s true or at least a 99.5% specificity or something in that area. Because if not, given a relatively low prevalence of the virus, you can have more false positives than false negatives, and if you don’t adjust your data accordingly, that’s a real problem. Another issue which is related is how many carriers are asymptomatic?

We know typically the course of the illness is mild, but then in addition to the people who have mild symptoms they might attribute to the cold or the flu, you have people who have no symptoms at all. Data from Iceland and from Florida, from that Miami study, suggests up to half of people who carry the virus don’t have symptoms. 

So, how many people are immune? Now, the extent and the duration of immunity is unclear.

We assume that having been infected confers some immunity. That’s the general theory underlying efforts to develop a vaccine. But the prevalence that’s required to achieve what they call herd immunity, which means enough people are infected that you either dramatically slow the progress of the epidemic or actually stop it, may range anywhere from 40% to 80%. That’s far higher than the prevalence rates estimated from these antibody studies. 

Another question: What share of the population might ultimately be infected? You see estimates all over the place, a quarter, a third, half, two-thirds.

Other things being equal, you would expect this virus to spread further than, say, the seasonal flu, because it’s novel. These people don’t have immunity to it through vaccines, through infections in prior years. But of course, we have to take into account social distancing, both as a matter of government policy and as a matter of social practice, which will affect the extent of transmission.

You should note that there’s a tension between the goal of reducing transmission over the short to medium term, and the goal of achieving herd immunity, which, assuming a vaccine is going to take a year or two to develop, presumably herd immunity is something you want. But you really can’t achieve herd immunity unless you allow the virus to be transmitted.

How fast does the virus spread? Well, the assumption is that it spreads faster than the seasonal flu, given the lack of general immunity. But so far, you don’t see the kind of penetration that you do with the flu. A flu can affect up to a billion people in any given year. The total number of confirmed cases worldwide is currently 3.7 million. That is probably a vast undercount, but even allowing for a lot of undercounting, it doesn’t, so far, seem to have penetrated as much as the flu typically does.

That difference may have a lot to do with social distancing, both mandatory social distancing and voluntary measures — not just the lockdowns, but also things like avoiding crowds and handwashing and wearing masks and working from home and so on. But you also have to consider we’ve only had about four months as opposed to a full year of this epidemic. That may also explain why we don’t seem to be seeing as much prevalence as you do with influenza. 

Another crucial issue we don’t know: How deadly is the virus? What share of people who are infected by it can be expected to die as a result of the infection? We have crude case fatality rates, and this is the percentage of confirmed cases that result in death, or the percentage of reported deaths as a share of confirmed cases. These are all over the place, if you look across countries or across states within the U.S.

Just to give you few examples: The current crude case fatality rate is about 0.6% in Iceland; 1.5% in Israel; less than 3% in Texas, where I live; also less than 3% in Hawaii, where you guys live; around 4% in California and Germany; about 6% nationally in the U.S.; 7% in Louisiana; about 7% worldwide; 7% to 11% in New York City, depending upon whether you include cases that are suspected but not confirmed by laboratory tests; about 14% in Italy; and about 15% in the U.K.

These numbers, like I said, are all over the place, and you have to keep in mind that there are some problems with the crude CFR. First of all, you have unknown deaths. People die from the virus, they may die at home, they may have other illnesses,  and they may be missed. That certainly is happening to some extent, we don’t know to what extent. 

You also may have the opposite problem, that deaths among people who have tested positive for the virus are attributed to COVID-19, even though the virus didn’t actually cause those deaths.

Finally, the most important problem is that the total number of cases is going to be vastly underestimated because testing, especially in places like the U.S., has been skewed toward people with the most severe symptoms, and those people are not representative of infections in general. Infections typically do not result in serious symptoms, where people have symptoms that are typically mild, and as I mentioned, perhaps up to half of people who get infected don’t show symptoms at all.

We know that there’s a problem in the numerator, we know that there’s a problem in the denominator, the problem in the denominator is going to be much bigger. The error in the denominator is bound to be much bigger than the error in the numerator. Which means  that overall, these crude case fatality rates are going to overestimate the actual percentage of people who will die as a result of being infected by the virus. One reason that the crude case fatality rates may vary so much is that different places are in different stages of the epidemic.

You may also have different ratios of total infections to confirmed cases depending upon testing rates and practices. You may have different age demographics in different places, which is going to affect the death rate. You may have different rates of pre-existing conditions. You may have different demands on the healthcare system, (and) the healthcare systems may be of varying quality, to begin with. Possibly —  there’s not much evidence for this, but possibly — there might be different varieties of the virus that happen to strike certain places, which might be more deadly.

So, if you’re trying to figure out what is the actual infection fatality rate, the percentage of people who are infected who will die as a result of being infected, we have some estimates, again, from antibody studies. A drift study in Germany said about 0.4% of people infected will die. L.A. County and Santa Clara studies put it somewhere between 0.1% and 0.2%, so even lower than in Germany. The Miami-Dade County studies said around 0.2%. The study in New York State in New York City, they put it at 0.5% or 0.6%.

These numbers vary pretty widely, but they are all much, much lower than the crude case fatality rates. Let’s just talk a little bit about the policy implications. What happened in the U.S. because of this test shortage is that we could not pursue a strategy similar to what was done in Iceland and South Korea, where they emphasized early and wide testing, isolation of patients, quarantine of carriers, contact tracing to see who else had been exposed.

Those strategies seem to be successful, judging from the fatality rates per million people in those countries, which are far, far lower than what you see in the U.S. or in Europe. But we couldn’t do that. We simply didn’t have the testing capacity to take that targeted approach. What we ended up doing instead is imposing these wide, sweeping lockdowns, saying nonessential businesses had to close, people had to stay at home unless they had a government-approved reason for leaving their homes, and all of those policies were imposed without the knowledge that really was necessary to assess their costs and benefits.

Because if you don’t know how far the virus has spread in your state or in your city, if you don’t know how many people have been infected, how many are currently immune, how deadly the virus is, it’s essentially impossible to weigh the cost of benefits of any given policy. We know that the costs of lockdowns are huge economically. I don’t like to phrase it in terms of — you often will (hear) people say, this is a matter of money versus lives, and obviously we should choose lives over money.

It’s really a matter of two kinds of human costs. You have obvious human costs on the disease side of it, that people are getting sick and people are dying, and you want to prevent that as much as possible. But you have enormous human cost at the other side of this: people are out of work, millions of people thrown out of work losing their businesses, struggling to pay their bills. That’s a huge cost that is ultimately unsustainable over the long term.

We have to figure out how to get out of that. But the transition is also hard to calculate in the absence of hard data on the prevalence of the virus, it’s deadliness and so on. I think these variables that we don’t really know are going to end up being different from place to place. That’s what’s suggested by the numbers that we have so far, that the conditions are different from one place to another, depending upon things like population density and other local factors, in terms of health profile, age of the population, the quality and capacity of the healthcare system. So it makes sense to have a variety of approaches depending upon what the local conditions are. 

One thing that needs to be considered in weighing the cost of benefits, and I’ll just close with this point, is that it’s very clear that deaths from this disease are concentrated among people who are elderly and/or people who have serious pre-existing conditions. That certainly does not mean those deaths don’t matter, but it does make a difference. If you had an epidemic that was primarily killing healthy young people, children, teenagers, younger adults, that would be a much bigger loss and a much bigger cost to weigh than if you have people who are dying — for sure, many of them are dying earlier than they otherwise would have — but you are losing on average fewer lives, and that really makes a difference.

I know people think that that is uncouth to bring that up or inhumane in some way, but governments routinely weigh costs like this when they’re deciding whether to implement particular public health or public safety regulations. You really need to take into account not just lives lost, but life years lost. I’ll close with that, and I’m happy to take questions.

Akina: Jacob, thank you very much, excellent presentation. As Jacob said, he’s open to questions from the audience now. But first, let me kick off with this: You’ve touched on it already, but I’d like you to amplify your response to this issue — how valid is the herd immunity thesis? How does a lay person who’s nonscientific determine whether that’s a good frame of reference to be proceeding from? Secondly, along with that, if our government embraced that thesis more fully, what policy changes would we have seen in the response to the coronavirus? Go ahead.

Sullum: Generally speaking, the idea of herd immunity is valid. The more people become infected, the more people who then presumably become immune. Obviously, the harder it is for them to catch it, … the harder it is for them to pass it on to other people. That’s crucially important, especially to people who are especially vulnerable to the disease. So older people, people with serious pre-existing conditions — this would help protect them.  

The question is, how do you achieve that? I think I mentioned there’s a wide range of estimates for what percent of the population this requires. The estimates I’ve seen range from 40% to 80%. That’s a pretty big range, but we’re pretty clearly not at that level, even in New York City, yet, judging from the antibody studies. The question is how do you achieve such a substantial prevalence of the virus while maintaining severe restrictions that are aimed at preventing transmission? 

On the other side of it, how do you allow transmission among relatively healthy and young people without endangering the elderly people, or people who are in poor health? That’s the tricky balance, because what else is the endgame? You can’t maintain lockdowns forever. We can’t wait for a vaccine; it’s going to take too long unless there’s a huge surprise. So, some level of herd immunity seems like it’s going to be necessary to get us through that transition.

So you have to try to come up with ways where you can protect especially vulnerable people, while at the same time allowing people who are at much less risk to actually get the virus and recover.

Akina: Thank you, Jacob. I’m going to hand off to Joe Kent to moderate the question-and-answer time. Joe, go ahead.

Joe Kent: Sure, thanks. We got some great questions, and please feel free to ask more questions. We’d love to hear your thoughts. The first question I have is from Joe Cobb, and he asks about the BBC News report today (that) Britain is the worst in the EU for the virus. How much blame should go to the government-run hospital system for that?

Sullum: I haven’t studied the U.K. in detail. I will say it is true that they have a relatively high death rate and a relatively high crude case fatality rate, higher even than Italy right now. So that’s not good. The quality of the healthcare system is something that you always have to consider. I think they claim that they were never actually overwhelmed.

I recall Neil Ferguson, the British epidemiologist, saying that while systems in some parts of the country were stressed, they were never so far above their capacity they couldn’t treat people. So I don’t know whether that’s true or not. Another thing to consider in terms of stressed healthcare systems, is that you have several things going on here. You have, obviously, if there are too many COVID-19 patients and they can’t be treated, some of them are not going to get the care they need.

Also, you have people with other conditions who may either be unable to be treated because the hospitals don’t have the capacity because they’re overwhelmed, or because there have been legal bans on so-called elective procedures, which include a lot of potentially life-saving procedures like biopsies in cancer and heart treatments. Also, people may be so afraid to go to the hospitals that they just avoid medical care — they’re afraid of catching this disease. So you have a bunch of factors that go into that.

When you look at something like excess deaths, how far above the rate of deaths that you would expect are we (at) now? That’s the question you often ask, especially if you’re trying to identify COVID-19 deaths that were not officially recorded. You can’t attribute all of those excess deaths to COVID-19, at least not directly, because there are all kinds of things going on at the same time, and not all these people were actually killed by the virus. But it may have something to do with either the virus, the epidemic’s impact on the healthcare system, or the government’s impact on the healthcare system.

Kent: Also there are a lot of hospitals that seem to be empty right now, and that’s stressing those hospitals as well. Hospitals that are empty, some of them might be laying off workers and so on. 

Another question, for your thesis — you’re talking about the CDC and the FDA … getting in the way — but what about the argument that they’re just trying to protect folks from false positives and false negative tests?

Sullum: I think that’s obviously a valid concern, but the review process certainly could have been quicker than a month, for example. They can provide provisional approval, which is what they were supposed to be doing based on data that’s submitted by a company. So if you have a reputable pharmaceutical company and they say, “We’ve produced this test, here is how we know it works, we’ve done these validation studies,” the FDA doesn’t actually have to repeat those tests immediately. It can say, “For now we’re taking you at your word. If we find out you were lying, you’re going to be in trouble later on,” that sort of thing.

In fact, that is basically what they ended up doing. So you have, for example, in the case of antibody tests, you have dozens of tests that are currently available, and the range of sensitivity and specificity is fairly wide. But some tests, at least according to the numbers from the manufacturers, are quite good, if not 100%, close to 100%. Again, like I said, a lot of these are reputable companies, and we don’t expect that they’re simply lying.

Some of them may not be, some of them may be shadier, and that will have to be sorted out later. Certainly, it’s going to be important to replicate those validation studies when it comes to picking a test that will determine who’s allowed to go back to work and under what restrictions, based on whether we think they’re immune or not, for example. Or, what do we think the actual prevalence is of this virus within this jurisdiction?

Governments that are using tests for purposes like that will want to be pretty confident that the test is reliable. So you need to do further research, or in the case of New York state, what they did is they developed their own antibody test in-house, which apparently they have confidence in.

Kent: Tim Means asks: Here in Hawaii, there’s a great concern about opening up to tourism; however, our economy depends on visitor spending. We have a 14-day quarantine that tourists have to abide by when they come here. What do you think is the path to opening up tourism?

Sullum: Well, I would hope if you can lick this — the testing problem — that would solve that issue as well. If you can screen people, ideally, you want to screen each visitor for both the virus and antibodies. The virus test tells you, are they carriers? In which case, a 14-day quarantine is probably a good idea. And the antibody test tells you, were they exposed at some point in the past and are they now presumably not only not carriers, but presumably immune?

Quest is now offering through an online portal for $119 each an antibody test where you get results within a few days. Other tests can give you results within hours. That capacity has to be scaled up so they can deal with things like: Who are we going to let into our state, traveling internationally or traveling from other parts of the country? I think testing is ultimately the solution to that.

Kent: Joel Van Brunt asks: It appears that a robust public discourse has not occurred regarding who actually makes the risk decision, the state or the individual. In other words, should the state be telling us how much risk we can take,  or shouldn’t that be an individual decision? How do you view that question?

Sullum: Well, I think when it comes to risks that you are accepting for yourself, certainly you should be in charge of making that decision. The problem with a communicable disease is that you are also potentially imposing risks on other people. The theory behind the lockdowns was: We don’t know who’s carrying this disease, so everyone’s got to stay at home. And it still seems insane to me, in retrospect, that that was the solution. But again, like I said, that’s because they simply did not know. They had no way of knowing.

Ordinarily, with a quarantine, it’s a particular individual or group of individuals, or sometimes it might be, say a whole neighborhood that you know is rife with a particular disease, and you say, “We’re going to quarantine this person or these people because we have good reason to believe that they are actually carriers and pose a threat to the general public.” 

In this case, governments made no distinction based on the level of risk that individuals or groups of individuals posed. They simply said, “Any one of you could be a carrier; therefore, all of you have to obey these rules.” And that is obviously less than ideal, and if we had had testing capacity, we wouldn’t have had to do that. 

I do want to note that there is a legitimate role for the government in protecting the general public from contagious diseases, but it needs to be done in a way that is proportionate and balanced. Cases involving individual quarantines, if you look at state laws dealing with the classic quarantine, there is a balance. It’s, “This particular person is alleged to be a disease carrier.” But that’s not the end of the story. He can challenge his detention. He can go to a court and say, “I’m not really a carrier,” and the government has to present some proof that he actually is. So there are safeguards for individual rights. In that situation, we’re isolating just one particular person.

But when you’re isolating hundreds of millions of people, somehow there is no balancing, there’s no test. So far — I was just writing about this today — the court cases had not gone anywhere, for the most part, except for in limited contexts like drive-in church services. General challenges to these sweeping restrictions have not gotten anywhere because the courts tend to say this is a matter of public health, and that’s entirely up to the state.

Kent: Basically, if we have more information, we’re better able to make our own risk decisions individually, I guess. What about, though, the cost to keeping the economy closed? There’s a cost to lives, but there’s also an economic cost. Helen Wagner asks: Suicide seems to be another consequence appearing as well as mental health issues due to a loss of jobs, loss of homes compounded by the fear of the unknown due to the lack of transparency and loss of voice. What alternatives does the average citizen have? Isn’t there a cost also to closing?

Sullum: For sure there’s a cost. There’s an immediate cost that we are starting to see in terms of millions and millions of unemployment claims, a huge unemployment rate unseen since the Great Depression. We know right up front, trillions of dollars in government spending that is largely attempting to compensate people to some extent for these losses. We know there are big losses in terms of output over the short term. The bigger question is, what about the long term? How quickly will the economy recover? Is this going to be a recession as severe as the last one, or worse? We honestly don’t know.

That part is uncertain. We know right now there are huge costs that are being borne by millions of people throughout the country. Like I said, you can’t discount that, you can’t say, “Oh, that’s just a matter of money. Lives are more important,” because while lives certainly have a big value, that value is not infinite. It cannot be infinite because we don’t have infinite resources. So human costs on both sides of this equation really have to be weighed.

I think, initially, the economic cost did not get sufficient weight because the incentive for politicians was to seem like they were doing something in response to an emergency, like they were saving lives. Look, to some extent I have no doubt, it did save lives. When we’re talking about lockdowns, we should be clear we’re not talking about the difference between lockdowns and nothing. That was never an option. It was never going to be, we would just continue as we’ve always lived and just ignore this epidemic, or we’re going to have lockdowns.

The choice is between lockdowns, and policies and measures that are less sweeping and more targeted — so, the voluntary measures I mentioned, but also less severe government restrictions. So you’re seeing things like restaurants may reopen but only outdoor seating or only at this capacity. Certain kinds of businesses can open up as long as there’s social distancing and maybe masks and maybe gloves. These are less severe restrictions that at least allow businesses to operate and allow people to go back to work. But there is a cost to that, I don’t want to deny that.

There is some marginal benefit from having the total shutdown as opposed to these less sweeping measures. And for sure, you will see, you’re going to see, increases in cases, you’re going to see increases in deaths. And some of that will be attributable to somewhat less social distancing now that people can go back to work. I don’t want to deny that. But the question is: How do you weigh that loss against the huge ongoing economic loss to people and which, by the way, this is most severely hitting the people who are most vulnerable.

On one side you’re worried about people whose health is most vulnerable, or most likely to be killed by the disease. But on the other side you have people who are economically most vulnerable, who can’t afford, like Larry David said, to just stay home and watch TV all day long. It would be nice if they can afford to do that, I’m sure they would love to. But not everyone can afford to do that. If you have half a billion dollars, like Larry used to have a billion dollars. If you have that kind of money, then you can afford to lie around all day. But most people can’t afford to do that.

Kent: What about people who say that, “Well, looks like the government saved us.” They locked it down, our death case fatality rate in Hawaii and other places are very low, so, doesn’t that mean that the government saved us somehow?

Sullum: Not necessarily. What we can observe is the government did X and then we saw Y. We can’t say that X caused Y. You can’t answer this question with much confidence unless you run an experiment, which we are sort of running now. We’re sort of through federalism running an experiment where we see states taking different approaches, some going more quickly than others. And you will start to see what happens after they do that. But you can’t be fully confident unless you actually do a controlled experiment, which is neither feasible nor ethical to do.

We can say that some of the places that did not have lockdowns, places like Iceland, Korea, to a lesser extent but still true of Sweden, seem to have their epidemics under much better control than places that issued lockdowns do. What that suggests to me is that the lockdown was not the only approach that could have worked, it was the approach that we chose.

Over time, given social distancing measures including the ones that are not government-imposed, would have had an impact on transmission, would have had an impact on cases and deaths. So it’s difficult to calculate the marginal contribution of the lockdowns, although I’m sure there was some marginal contribution.

Kent: Did the government get in the way of antibody testing? I mean, there’s tests and then there’s antibody tests. Are those available enough and do they work quick enough, and would they help?

Sullum: The tests are pretty widely available now. I think that the government learned a lesson from what happened with the virus testing, and they were a little bit quicker with the antibody testing to say, like I was alluding to, “Show me your data and you can go and market this, and we’ll check up on you later.” 

One thing to keep in mind with the antibody tests is that these reported rates for sensitivity, which means if you have a whole bunch of samples that should be positive, what percentage of them does the test detect is positive, and specificity, which is you have a bunch of samples that should be negative, and what percentage are correctly identified as negative? (These are) two rates that are reported by companies that make antibody tests. You can have a rate that seems pretty high, especially for specificity, like 90% sounds like a good rate, but if you have a 90% specificity rate in the validation test, where you know what all the samples are, you know they’re all negative. If you go out into the general population and you start testing people, if the prevalence of the virus is relatively low, which we assume it is, let’s say it’s 5% in the U.S., with the prevalence is that low, you’re testing lots and lots of people who should be negative.

So, even if the rate of error in the validation test was low, when you have so many people who are negative, you can end up with a situation where you have more false positives than true false positives. That means you take this test, it’s supposed to show whether you might be immune or not, and actually, given a 90% a specificity rate, it’s more likely than not that you’re not immune if it comes up positive. So you don’t want a test that’s only 90%. You want a test that is at least at 99%, if not 99.5% or 100%.

That’s something to keep in mind, but that is something you can find out on your own — and at least if you’re getting this from a reputable company, you can be pretty confident they’re not making stuff up — where you could look at those rates which are published and figure out does this make sense for you, is this going to get you the confidence that you need to go back to work or to go out in public? Can you be around your elderly relatives? That sort of thing.

Kent: What about also the theory that if you have caught it before and you recover that you’re not necessarily immune?

Sullum: It’s possible, we don’t know for sure, because it hasn’t been actually tested. What we can say is, based on the experience with other coronaviruses, with seasonal flu, for example, people do tend to develop immunity, and it does tend to last for a fairly long period of time. This is one of the reasons why people were so much more afraid of this particular virus than they were of the seasonal flu. Also, obviously, it looks like it has a higher fatality rate. But the fact that people were not immune suggested that it could spread a lot further.

The assumption there is that, yes, having been infected in the past provides some level of immunity. We don’t know exactly how much or for how long, but it’s obviously better than not having any immunity at all. And like I said, if vaccines are going to work, it’s by stimulating an immune response, and we’re assuming that that does prevent you from catching the disease and transmitting it to others.

Kent: How about, Mark Coleman asks, regarding the testing, are you suggesting that they should be mandatory? Isn’t it impractical to test every single person in the U.S., and what about testing tourists and other travelers, which is an issue for Hawaii. Should they be tested, quarantined or required to wear monitors and all that? What do you think about that?

Sullum: It is currently clearly not practical to test everyone in the United States. What the CDC should be doing, and what state public health authorities should be doing — they’re beginning to do it, like in New York, they did it — is testing representative samples in different places. If we test people in New York City like they did, we get some idea of the prevalence there. We test people —

Kent: Would that be voluntary, by the way, or mandatory?

Sullum: Yes, these studies I’m talking about are voluntary. You draw a representative sample, you say you’re willing to participate in the study. You draw the blood, you see what percentage of people in this sample that’s designed to be representative have been infected. That gives you some idea of prevalence in a particular place. That’s very important to know. That’s completely voluntary. In terms of something like controlling people who visit your state, if I come to Hawaii, I would much rather get tested as the price to admission than go into quarantine automatically for 14 days.

If you do that, that basically ruins your vacation. You have no vacation. But at least if they tell you in advance, “Look, you’re going to have to take this test; look, you can take it on your end.” You don’t actually have to travel first. You take the test on your end, find out, and then you can go with confidence. That, to me, seems like a reasonable restriction for a place, especially a relatively physically isolated place that’s worried about travelers who are carriers. It seems less onerous than saying you’ve got to go into a 14-day quarantine.

By the way, I wanted to correct something: Larry David’s net worth, (laughs), I should have said it used to be about a billion dollars before his divorce, but now it’s more like half that. I don’t begrudge him any of it. I just think maybe he has a distorted view of what it means to be out of work and stuck at home, given the socioeconomic status.

Kent: Right. We have a lot of questions about, just how does the virus work? One person, Kanoe, asks, how long is the course of the virus? Go ahead.

Sullum: The estimates of the incubation period range from 2 days to 14 days. I believe the median length is 5 days. That means, even among people who are going to develop symptoms, they can be carrying the virus for at least several days before they have any reason to suspect that they’re infected, and they can be transmitting it to others. Obviously, that’s worrisome. That’s a longer incubation period than you see typically with the seasonal flu.

Then, of course, the other issue is some people never show symptoms at all, or at least none that are severe enough for them to notice, or they may be so mild they attribute it to the cold or the flu. That’s a pretty long period. This is where they get the 14-day quarantine from, is the idea (that) by then,  you should either have shown symptoms or you should have recovered and you should be clear. The time from infection to death can be up to a few weeks.

This is why when you look at Santa Clara County, California, and you see a woman who died on Feb. 6, and it turns out it was caused by COVID-19, and furthermore, she did not get infected by international travel or even by somebody who had been traveling internationally, that tells us that sometime around mid-January, this virus is already spreading in Northern California — which is considerably earlier than they thought to have local transmission.

That raises new puzzles, like: W hy does the virus seem to be having a much less severe impact in California than it is not just in New York City, but in New York state? It’s important to take those things into account. Then you also will, if you’re monitoring these numbers as the days and weeks go by, you have to keep in mind that death is a lagging indicator, that if somebody’s dying now, it means they got infected two or three weeks ago, and that was the state of the epidemic at that point.

Kent: One last question here. William Ahuna asks, is there any evidence of retrovirus? I don’t know — that’s a term I’m not unfamiliar with. Any evidence of a retrovirus attached to COVID-19 making mortality higher in a certain population?

Sullum: I alluded before to the possibility that there might be some varieties of the virus that are more deadly than others. There is no hard evidence for that at this point. There are genetic variations, and this is how they can estimate things like how many people do we think came into New York with the virus initially that started the epidemic?

This is one of the reasons why New York seems to be doing so much worse, is that you had up to 100 international visitors mainly from Europe coming in with the disease, and they know that by looking at genetic variation. The big question is whether any of these variations are significant enough that they actually would result in a higher death rate, and that we don’t know.

Akina: Jacob, thank you very much. Excellent answers, great presentation. Thank you for joining us from Dallas. We appreciate it so much.

Sullum: Thank you.

Akina: Next webinar, everyone, don’t go away yet. Remember Tuesday, May 12, at 12 noon, we’ll have Steven Greenhut with us answering the question, “Could Hawaii go bankrupt,” especially because of the costs of dealing with the coronavirus? Finally, encourage Gov. Ige. He took a tremendous move today in starting to reopen the economy a little more, and help him to know that he’s heading in the right direction.

Go to lethawaiiwork.com. That’s lethawaiiwork.com, and join more than 5,000 others who have signed this petition put forth by Grassroot Institute. 

We’ll see you next time, much aloha. I’m Keli’i Akina. Thanks for joining us today.


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