The Real World

COVID: Some Ways Out

(4000 words, ~12 minutes to read)

It’s easy to get stuck in the day-to-day mire of COVID-19 statistics, analyses, and hot-takes. But what I really want to know is: What might a post-COVID world look like? And what are some ways to get there? In this highly-speculative spirit, here are some ideas (none are original, I’m just compiling ideas I’ve heard from various sources).

1. A Vaccine

This is the solution I hear about the most, by far. COVID is a virus, as is the flu or measles or smallpox (technically, Sars-Cov-2 is a coronavirus which causes the disease COVID-19, but I’m going to keep calling it COVID for short). One thing we do to mitigate the effects of those diseases is to vaccinate the population, either in childhood or annually; this allows the production of antibodies in healthy individuals, mitigating the spread of active virus cases. We might want to do this for COVID.

Best-case, it works extremely well, COVID stops spreading, and the global caseload starts dropping until it gets to zero; you might call this the smallpox model, mapping to the eradication of that disease in the late 20th century. Less-than-best-case, it works kind of well but COVID keeps spreading; the caseload goes down but does not get to zero, as the virus keeps mutating to stay just out of reach, and we see new outbreaks popping up year after year. This is the flu model, where we have to get a new vaccine every year for new strains of the virus and tens of thousands of people still die from it annually.

If the vaccine works, we won’t know which model (smallpox or flu) we will get. Still, while not perfect, even the flu model is far better than what we’re doing now, which has cost trillions of dollars and the virus still runs the risk of overrunning hospitals if we let up even a little. A vaccine at least might keep the virus at bay in a way that is manageable in the long run.

Big drawback: Unknown (but likely long) Timescale For Development

Vaccine development takes time. The timescale I hear quoted most often is 12-18 months, though many hold that this is extremely optimistic, pointing out that most vaccines in the past have taken decades to develop. We have the benefit of modern technology and resources, sure, but science is science, and you don’t know how easily the answer will come until you already have it.

It’s also worth saying that there’s a lot of pressure to get a vaccine out as fast as possible–and rightly so–but this will potentially mean governments will be incentivized to cut corners with respect to safety testing. Say what you will about how “vaccines are safe”, but I’ve seen enough zombie movies to know that a new global vaccine has risks. Seriously though, our ability to ensure safety depends on a lot of testing and tracking populations over time; it’s very possible to produce a bad vaccine if we’re not careful. Given that it would be eventually distributed all around the world, some caution is in order… but delays mean more COVID deaths. This is a difficult tightrope to walk.

And once a viable vaccine is in hand, it will take a long time before it can be distributed at-scale around the world. People are already arguing about how we should decide who gets a limited supply of vaccines first (market forces? focus on at-risk populations? a lottery system? should the country that develops the vaccine get “first dibs”?). You can say “make the vaccine free” until you’re blue in the face, but at first it will be expensive and Humanity will have to ration it somehow. You can’t just snap your fingers and make 8 billion doses; time and resources are limited and it will take effort to get to scale. There are better and worse ways of doing this, and I’m glad smart people are thinking about it early.

Even if it “only” took three years to find and distribute a really good vaccine, hundreds of thousands are likely to die before we get things under control. This is because, despite how good Hammer and Dance sounds, my point of view* is that so far it hasn’t worked very well. We are seeing time and time again around the world that after an initial Hammer (hard lockdown), the Dance (mild social distancing measures, reopen businesses subject to rules) doesn’t last long before a new large outbreak occurs and a new Hammer is needed.

(* Evidence, you say? Consider the clear “first wave” ➔ “short Dance” ➔ “second wave” patterns in Israel, Japan, Australia, and now much of Eastern Europe. On the contrary, South Korea and New Zealand have also seemingly kept the Dance going for many months in spite of nonzero virus counts; nonetheless, given the speed at which infection can spread, the risk of a second wave continues to linger over the heads of everyone. *)

While we’re in the business of getting the caseload down, we might consider…

2. Hard Lockdown and “Green Zones”

As long as there are even a small number of new cases per day, you run the risk of starting the clock all over again. Which potentially suggests, maybe we should keep lockdowns going until there are no active cases; keep the Hammer hammering until there’s nothing to hammer. Once there are no active cases in your country, life can truly return to normal, with gyms, beaches, concerts, and everything else you have missed. You wouldn’t even need to wear masks or social distance anymore.

In this model, a country that achieves truly 0 cases becomes a Green Zone, safe for travel to and from other Green Zones without worry. If Israel becomes a Green Zone, I can fly to any other Green Zone country anywhere in the world without testing and without masks. Truly, life goes back to normal, at least within the Green Zones. These rules would have to be followed closely, because one slip-up that leads to new cases demotes the country to a Yellow or Red Zone (depending on the specifics of the proposal), and lockdowns go back into effect.

A country like Sweden can go ahead and do nothing about COVID if they want, but they’ll be classified as Red and won’t get to partake in global travel (and in some cases, trade) with other Green countries. This incentive for the global community to buy into a common strategy; if you fail to Go Green, you fall behind. Such pressure could increase adherence within and cooperation between countries.

This strategy seems to have worked in a select few countries around the world. China hammered hard at the first peak back in February, and successfully held steady at 0 active cases for several months. However, other countries didn’t follow suit and so we’re probably seeing Yellow/Red Zone countries reintroducing the virus to China in recent days.

Big drawback: Hard Lockdowns are Hard

The main argument against hard lockdowns is economic: a proposal like this likely means shutting down the vast majority of the economy in a country for a month or more. Your local restaurant or hairdresser can maybe withstand decreased traffic for a few weeks, but a month or more of zero revenue is too much for many to survive. On top of this are increased unemployment rates, which in e.g. the US and Israel shot up to 15% and 40% (respectively) in their relatively short lockdowns in May. People need to feed their families and pay their rent; if they can’t work, many can’t do that. Given that 49% of Americans were expecting to live paycheck-to-paycheck in 2020 in the months before COVID, it’s hard to imagine regular people weathering this storm on their own.

The government might step in and provide direct stimulus, student loan or rent relief, or other hardship-relieving measures; many wealthy countries have done so already. But this is extremely costly. In the US alone, the relief efforts in total have come to $2.8 trillion dollars as of this writing (end of July 2020), not counting lost revenue from deferred student loan payments or the broader economic impacts outside of direct government purview. Still, the median American only received cash-in-hand on the order of $1200, hardly enough for a few months rent, let alone other necessities. Another major stimulus is likely to follow soon, costing potentially another trillion dollars, which would provide the typical American with only a second $1200 check.

And what about poor and developing countries? They may not have the resources to support people until caseloads drop to zero; people may be forced to choose between breaking quarantine (potentially getting beaten or shot in the process) and starving. If you’re concerned about global inequality now, wait until Europe spends its way to becoming a Green Zone while Africa stays Red, locking the latter out of tourism and global trade.

You could argue that all this cost is worth it, if at the end of it we get back to some semblance of “normal”. But, you may ask, if we’re going to spend so much, why can’t we spend that money on something preventative, without the additional costs, ruined businesses, and unemployment? Which brings me to…

3. Mass Testing

Knowledge is power. Now that we are starting to understand the transmissibility of COVID, we might be able to use smarter strategies than “lock everyone in their houses until the virus gives up”. If we had confidence that we could identify the people who were infected, we could selectively quarantine them while the rest of the population lived their lives in a nearly-normal way. Perhaps with enough testing, we could lock down smarter rather than harder.

We’re already seeing baby versions of this idea in specific industries. Airports around the world are looking into mandatory testing for all passengers, the idea being that a traveler will stay quarantined upon arrival until receiving a Negative test. In most proposals, the cost of testing is paid by the passenger (think of it as one more fee when you buy your plane ticket), and you may be able to pay more for a faster test.

At scale, a country could require testing of every citizen frequently, maybe as often as once or twice a week. If you are Positive, maybe you are sent to mandatory quarantine; if you are Negative, you carry your certificate around with you but otherwise live life as normal. This can be government-mandated, if you are ok with that, in which case there would potentially be a central database that tracks the movement of infected individuals. Alternatively, it could be up to local businesses whether or not to require your Certificate of Non-Infection before entry to their establishment.

I first heard a strategy like this discussed in detail by economist Paul Romer in a recent Econtalk episode (see his simulations of COVID spread here). Basically:

Well, whether you’re trying to use just population testing or whether you’re trying to use testing plus tracing, the goal here is to figure out who’s infectious, because the only way to stop or suppress this virus is to find a large enough fraction of the people who are infectious, get them isolated, so they don’t infect more people, and then you’re on this path where the number of people infected is falling over time.

So, you just have to find enough of the people who are currently infectious and get them isolated. If you do that, you don’t have to interfere with the activities of anybody who is not infectious.

You don’t have to find every single infectious person, and of course you won’t; false negatives will occur at some rate and those people will still spread the virus. But if you get enough infections off the street, it might be enough.

The key is that, this is not going to wipe out the virus, but it means that the number of people who infected will be steadily decreasing over time. If R0 number is less than one, so you get a steady decrease. And, that’s really all we can hope for.

(R0 is defined as the average number of new infections per infected person, a measure of how fast the virus is spreading.)

It’s a huge upside that most people will get to live their lives normally. Another upside, though, is that given that this won’t be the last pandemic we have to deal with, it’s a good idea to have a plan that can be reactivated with each new virus/disease. Once you have the infrastructure in place–factories and distribution outlets, facilities to do mass testing, and, importantly, a population that is willing to submit to it–you can repurpose all of that for COVID-20 or 21 at the drop of a hat.

So that when somebody says in the future, ‘Oh no, they’ve got SARS-CoV number three, or number four,’ which has emerged in some other country; we’ll say, ‘Well, we’re ready for it. Somebody is going to bring that into the United States, but we’re already testing everybody every two weeks. As soon as somebody shows up, we’ll find out where it is. We’ll isolate them. We’re good to go.’

To be clear, Romer’s plan isn’t the only proposal in this vein, but it captures the basic idea: test test test test test.

Big drawback: Testing is Costly and Invasive

COVID tests continue to be in short supply around the world (analysis from the US: free, paywall). Low supply and high demand means high price, which in time should drive more suppliers into the market, but in the short run we have to cope with the costs as they appear. To make a Romer-esque plan work today, it would take a huge investment in factories, distribution facilities, and testing centers today, and the payoff would only come later on.

Romer is hesitant to predict a cost for his plan, but he points out that the current situation is “costing us, in an order of magnitude, back-of-the-envelope, five hundred billion dollars per month.” When pressed, he suggests that his testing plan is maybe doable for $8-10 billion a month–a huge savings from the current situation, but this adds up a lot over time to more than $100 billion per year. Romer thinks it’s worth it: “…if you revisit a million people dead or a depression for eighteen to twenty-four months, a hundred billion on tests seems, to me, like a walk in the park.”

Compared to other proposals, though, this might be the most expensive overall. For scale, note that $100 billion per year would effectively double the discretionary budget for Health and Human services, exceeding the annual spending on Education ($74 billion) and quadruple the spending for NASA ($23 billion). A full-scale lockdown for two months would be catastrophic, likely leading to several trillion in stimulus to keep people afloat, but after that you don’t have to pay anymore; keeping the testing infrastructure going year after year adds up to trillions pretty fast. To maintain the benefit of preparedness in the event of The Next Pandemic, you can’t let that budget disappear; you likely keep paying a large fraction of it even during pandemic-free years. Maybe it’s worth it for preparedness, but it’s worth taking into account.

People may not willingly sign up for such a large-scale invasion of their privacy (as some will see it); some amount of pressure, social or otherwise, may be necessary to get people to get tested. Romer is optimistic about this too:

The modest version of this would just make it possible for everybody to know if they’re infectious; and most people aren’t going to want to infect their colleagues, they aren’t going to want to infect their friends. They’ll take heightened precautions.

But he’s open to some coercion:

The next step up would be to say, ‘Well, there’s certain things where, like, counterparties might not agree to do things with you unless you can show you’ve got a test result.’ Like, my dentist may not want to see me because it isn’t going to work for me to wear a mask when I’m in the dental chair. So, my dentists may not want to see me unless I get a test; and that’s his choice. I don’t think you need the government to force that.

I’m not as optimistic as Romer is, in part because of the current situation in the US. We haven’t even convinced people to wear a mask when they go to the grocery store; do we really think they’ll freely subject themselves to a nasal swab once a week? Some will reject it for the inconvenience, and others will reject it because they’ll see it as an invasion of their civil liberties. The latter will be true especially if there’s any level of government coercion involved: “The government wants to test my saliva every week indefinitely? No way!”

If you don’t like any of the above escape hatches–if the costs are too high, if the public resistance will be too great, if the uncertainties are too daunting–then you might be in the mood for…

4. Herd Immunity

“Ok,” some say, “COVID spreads too fast and the options for mitigating its effects are too costly. We just have to bite the bullet and let the virus spread to the whole population. Once enough people have it, the spread will slow, and it will eventually die off. Once we’ve all had it, we can get back to our lives and not worry about it anymore.”

There is evidence that herd immunity is possible. Once you accept the premises, it’s easy to understand: you already had the disease, so your body learns to produce antibodies that fight the infection, and so next time you’re effectively immune. If enough people get to this stage, then it won’t matter that your neighbor got infected, as long as most of the people they come in contact with are already immune; get to that point and the caseload would eventually come down on its own. It’s the same principle as widespread vaccination, though with an active rather than inactive case of the virus.

If it worked, the hope would be to get through the COVID era with minimal economic impact; people would be allowed to go to work throughout the pandemic and only send home if they were very sick, much like we do with the flu or a cold. People would still die, but people will also die if they can’t feed their families or pay their rent, so we may as well keep the economy running as long as we can.

It would take some time, because likely more than 50% of the population would have to be infected in order to achieve herd immunity. Given that a large fraction of those infected by COVID are asymptomatic, we are likely underestimating the total number of cases worldwide; this is good news for herd immunity, because we might be closer to the threshold than the reported numbers suggest.

Recent antibody tests in Israel suggested that as many as 10 times more people have been infected than the number of reported cases. CDC estimates for the US suggest similar: 10 times more infections than those reported; if true, the current total infection rate in the US might go from 1.5% reported cases (as of this writing, 4.3 million cases / 300 million population) to 15%. Is the US really a quarter of the way to herd immunity?

Big drawback: Overrunning Hospitals and Possible Lack of Long-Term Immunity

If you let the virus run its course without slowing it down, hospital resources are likely to run out and people who might have been saved by straightforward hospital treatment won’t be able to get the help they need; therefore more people will die than if you spread out the infections over several years, Hammer/Dance style. We saw this in Italy; we saw this in Spain; we might be seeing it in some parts of the US right now. (A more thorough list.)

Sweden has been the poster child for the herd immunity strategy, and by many people’s estimation, it hasn’t worked out well for them thus far. Recent antibody tests suggest only ~7% of the population has the relevant antibodies, while nearly 6000 people have already died, giving them the rank of 12th highest case fatality rate and 8th highest deaths per capita in the world. Case fatality rate (the number of deaths / the number of cases) varies a lot between countries, and we don’t know all the relevant factors in determining this, but I have to imagine that hospital overrun is part of this.

Compare Sweden’s death count to the culturally-similar neighbors Denmark and Norway, who combined only total <1000 deaths (and combined have close to the same population as Sweden). And to top it off, Sweden is still experiencing economic impacts at close to the same levels as its neighbors, in spite of its economy being ostensibly open this whole time. Turns out, people tend to stay home more and not frequent their favorite businesses when there’s a virus loose in the community.

Perhaps more damning for herd immunity is that it might not work at all. Since the very beginning of the pandemic, there have been reports of people who supposedly got reinfected; that is to say, these people had a positive test, then a negative test, and then tested positive again. It happened at the beginning and is still happening now. An optimistic view is that these very well might be scenarios of false positive or false negative. Even so, the virus can mutate and it’s possible that your immunity to one strain won’t protect you against another.

Further, there is independent research that suggests that immune response to COVID does not last forever, meaning that people really could become reinfected after some time. I don’t fully understand it, but in brief there was a paper recently reporting results of a months-long observation of COVID survivors and their immune response. They found a very strong antibody response during / just after the initial infection in March, but when the tested again over the following 90 days (until June), they found that the antibody response diminished with time. If taken at its strongest face-value, this could imply that people can be reinfected only a few months after recovering from COVID, which would violate the most basic premise of the herd immunity program. However, note that the story is complicated: immunity is not a one-to-one game, you may have partial lingering immunity from other sources, etc.

Conclusion: No Silver Bullets

These are the kinds of end-game strategies I’ve heard discussed thus far, and as I hope I’ve made clear, each one has very significant drawbacks. Short of a miracle, there is no Silver Bullet strategy that will get us out of this mess without a lot of death and hardship; it’s all tradeoffs, and many lives and livelihoods hang in the balance.

So in the end, which option is best: vaccine, hard lockdown, mass testing, or herd immunity? My own personal favorite strategy, for what it’s worth, is Mass Testing; I’m confident that there will be more pandemics and in the long run it would pay off to build infrastructure to deal with them as well. But I’m not very sure that this is the best option. I could be convinced otherwise.

The borders between proposals aren’t perfectly clear, of course; no matter what you do you’re going to need some level of tests, some level of social distancing or lockdown, and you shouldn’t deter people who want to work on a vaccine. But having a specific endgame in mind seems absolutely critical to me. Whichever option “we” choose (in a given country), we need to focus on that full-force. While politicians tend to want to hedge and go half-way, the current regime of half measures seem guaranteed to bring us the worst of both the biological and economic consequences.

If you’re going to do a hard lockdown, lock it all the way down for as long as it takes; if you’re investing in mass testing, invest enough to achieve real clarity about who is infected and who not. A half-lockdown coupled with partial testing capability just keeps hospitals at-capacity for months or years at a time, which is a virus’ dream scenario. (Remember that a virus thrives not when all its hosts die, but rather when the hosts allow it to keep spreading for as long as possible.)

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