With many states starting to reopen significant portions of civil society that were closed, it’s time to assess where we are and what should come next. Much of the commentary for the past month or so has revolved around widely varying assessments of the “real risk” from COVID-19. Opinions vary widely, to say the least.
Much of the argument has taken place in a rapidly evolving context which started with very little definitive knowledge. Unfortunately, many policymakers and much of the media cited epidemiological models created very early in the crisis and, declaring them authoritative, used them as the basis to justify mass shutdowns to “flatten the curve.”
When the dire predictions did not come to pass—a good thing—combatants on both sides dug into their positions. Those who had cited the studies generally have taken the position that the shutdowns worked and saved many lives. Those who oppose the shutdowns point to the fact that the numbers of hospitalizations and deaths are much lower than the models predicted they would be with shutdowns in place, let alone without any shutdowns at all.
The good news is that with so much attention focused on this one problem, we are learning about this virus more quickly than humanity has ever learned about any disease ever before. What can be done to end the threat of this virus and create a model for addressing the next one? Because, you can rest assured, there will be a next one. Novel coronaviruses are going to be with us for a while. How did we get here and what should come next? Are shutdowns really going to be the new normal?
I think that the best good faith argument for the shutdowns ordered in March is the following:
Political leaders were presented with a public health threat from a new virus about which very little was known. In America we had watched from afar as first China and then Italy locked down large portions of their countries to control the spread of the virus. At the time, it was unknown how contagious or how deadly the virus was. Add to this models developed by people considered experts in their field and caution was certainly warranted. No one with responsibility for other people’s lives wants to get people killed by ignoring such warnings.
Even today though, there are many open questions. The New York serology study shows that they got to 14.9 percent of the population infected at a cost of 15,000 dead. Using a straight line extrapolation means getting to herd immunity without a vaccine requires around five times more infections. That logic implies an ultimate death toll of 75,000 in New York alone and a rate of 3,845 deaths per million. (The population of New York state is 19.45 million).
If that logic were to hold, it would mean about 210 million cases of COVID-19 and around 1.25 million deaths in the United States over the next one to three years. That’s a fatality rate of roughly 0.6 percent. That would be pretty bad. Some COVID-skeptics would say that the seasonal flu never gets that bad, not even in 1957 or 1968. But COVID is different and has different outcomes.
And the existence of a vaccine helps keep seasonal flu to less than 60 million symptomatic cases even in a bad year. Even in 1957—the worst flu of the past century other than the Spanish Flu of 1918-1919—there was a vaccine within months of the pandemic beginning. I think there are lots of reasons that the straight-line extrapolation scenario is unlikely but that’s my best short version of the good faith argument behind lockdowns based on what was known in late March.
However, there are a number of things mitigating that view even assuming the New York study is essentially accurate. In some important ways New York represents the best large breeding ground for this virus in the United States due to its housing density, large household size in certain areas (Queens is a good example), and reliance upon mass transit. Other places in the United States are unlikely to repeat the New York experience, but that does not mean that they are risk-free.
The experience in northern Italy presents a potential counter to the argument that New York is different because there were severe outbreaks in mid-sized towns as well as the cities. But the virus simply hasn’t spread with the same intensity in places like Santa Clara County, California and King County (Seattle), Washington, both of which had early cases.
Contrast this with how quickly the virus spreads in closely packed environments like nursing homes, prisons, and meat-packing plants. But mitigating factors in such places are certainly feasible in those environments that allow them to operate safely and do not require locking down the whole country.
With states starting to reopen we can say, at least, that we’re at the end of the beginning. But we’re also not near the end.
So how do we proceed from here?
Let me begin with one encouraging note. The group known as “Scientists to Stop COVID-19” released a working document (PDF) that is well worth reading. This is a group of top scientists who have come together privately, organized by a young venture capitalist named Tom Cahill. He holds both an M.D. and a Ph.D. from Duke University. The group is operating independent of the existing public health bureaucracy with the goal of helping that bureaucracy to make good decisions quickly.
As one Nobel Prize winner in biology who is a member of the group said, “I’m the least qualified person here.” Their work has informed my own thinking.
Here are some steps that point the way forward:
1) Ubiquitous, on-demand testing is a necessity. So is cheap, plentiful personal protective equipment (PPE).
Whether we like it or not, so much psychological damage has been done that people are and will continue to be afraid. Without testing and masks we’re going to struggle with a fear hangover. This is where the failures of globalism are really evident: We don’t have the capacity to produce these things quickly and at scale in the United States. We should be creating that capacity now, but we’re not even doing that quickly. The domestic mask producers are trying to double or triple their capacity when it needs to be 20 times what it is now, according to the best estimates.
(For the best explanation of U.S. supply shortages, read “Why There Aren’t Enough Masks And How To Get More.”)
Testing must be greatly expanded. We’re currently testing around 200,000 people per day. We should be testing 20 million. Why? Arresting the spread of the virus is only part of the answer. Mass testing would allow a quicker return to normal because in addition to finding cases early, testing will give businesses and schools the confidence to reopen, employees and students the confidence to return, and customers the willingness to go to a movie or have a contractor in their house. Consider testing a vaccine against fear.
Already some small businesses have implemented regular testing programs of their employees where testing is available. What’s more, even without a mandatory testing regime, many businesses will want to test their employees regularly out of concern for their well-being, as a sensible risk management step to avoid an outbreak that could close the business, and also to protect themselves from potential legal liability. Lawsuits have been filed against employers for endangering employees, more are sure to follow.
Regular testing would provide a measure of protection for employers as evidence of their diligence in protecting their employees. The private demand is there now, yet we still lack adequate quantities of reagents necessary to perform tests at anything approaching this scale and in some states a doctor must still request the test. This is a place where the administration could be helpful in breaking logjams. And it should go without saying that the tests and the reagents should be made in America.
2) Study the long-term effects of COVID-19 on recovered patients. There is some evidence that the disease causes lasting damage to the organs, especially the lungs. If true, it significantly raises the risk profile of this disease.
3) The New York City metropolitan area needs to develop its own plan that takes into account its own unique situation which includes high density housing, densely packed sidewalks, and crowded mass transit systems. But New York City’s solutions are necessarily its own and largely will not be appropriate for the rest of the country. New York-centric media should be careful not to project the New York experience on to the rest of the country.
4) High risk people should take whatever precautions they feel are appropriate. This mostly means older people and those with risk-raising comorbidities like obesity, hypertension, and diabetes. Again, that will be impacted by where they live. Older people I know are aware of the risks and simply modify their behavior though those modifications are fairly minimal and mostly amount to avoiding large crowds, making shopping trips brief, wearing an N95 mask, and washing hands regularly. This will, of course, vary by people’s circumstances, where they live, etc.
5) Nursing home operators need a vigorous testing regime and employees need to be in N95 masks and gloves essentially at all times, along with a disinfecting regime. There are probably other things they can and should do, but that seems like a good start for the highest-risk environment. Given the large percentage of hospitalizations and deaths that are tied to nursing homes, extreme care is appropriate and necessary.
6) Other high density environments like meat packing plants need to have testing, barriers between employees as well as PPE requirements. There are probably other modifications that can be made to the plants that would make viral spread less likely. The chairman of Tyson Foods this week warned that “the food supply chain is breaking” as many meat processing plants have been forced to close due to outbreaks among their employees. Maintaining the integrity of the food supply chain obviously is essential.
7) State governors should have a bias towards reopening and a commitment to ensuring the wide availability of testing and treatment capacity. They must be forthright about the likelihood of additional outbreaks. These will happen, but they must be identified quickly and the patients treated.
8) The medical profession needs to treat this pandemic not so much as a one-time crisis but as an ongoing threat to be managed like we manage other diseases until there is a knock-out therapy or vaccine. There is reason for optimism that either or both could be available in the coming months, but nothing is guaranteed. What’s more, as novel coronaviruses are a recurring phenomena, developing plans for handling outbreaks effectively without resorting to mass quarantines is clearly necessary.
9) Government should drop “business-as-usual” regulatory barriers that delay therapeutic drugs and vaccines. Human challenge trials should be considered if it’s necessary to speed a vaccine as proposed by Marc Lipsitch, an epidemiologist at Harvard.
10) Understand that coronaviruses are now a fact of life. There are seven identified coronaviruses that are dangerous to humans, three of which are deadly (SARS-CoV identified in 2002, MERS identified in 2012 and SARS-CoV2 identified in 2019). There will be more, so we need to watch for mutations that could develop.
Will this become an annual event that mutates like seasonal flu? We don’t know, but people working in public health need a plan for this that is better than locking down vast swaths of the world. That was a stopgap measure.
Just as important, we need to develop the capacity to rapidly identify pathogenic threats, contain them, and treat them. That means establishing a separate regulatory framework specifically designed for rapidly developing public health emergencies.
11) We need to rebuild the public health infrastructure in this country and replace all of the leadership. The Centers for Disease Control’s response to COVID-19 has been a story of failure and incompetence. The tests they created in their labs in February were unusable because they were contaminated with coronavirus during manufacture as the result of the CDC failing to adhere to basic laboratory protocols.
Infamously, the CDC told Americans not to wear masks because they do not work before reversing that position a month later. And they touted flawed epidemiological models as nearly divine, inerrant prophecies rather than as what they really are: models of what could happen given a certain set of assumptions. Overselling the models undermined the CDC’s institutional credibility and public trust when the predictions were far off.
It’s time to clean house, end the gerontocracy, and bring in new leadership with a broad mandate to build a new, much more effective public health system. And we could do it at a tiny fraction of the cost of the trillions that are being spent in D.C. right now.
Now the good news. Scientists to Stop COVID-19 described four essential steps for getting COVID-19 behind us. They make a good deal of sense. They are:
1) Repurposed drugs. This is happening now. Existing drugs are being tested and used in real time to determine which are most effective in treating COVID-19. They believe that Remdesivir is the most promising and if current trials bear this out, it could be used with confidence while COVID-19-specific drugs are developed.
2) Antibody Therapies. There is a growing consensus that monoclonal antibodies will be the most effective treatment for COVID-19 and that they could be available by fall of this year. Two U.S. companies, Regeneron and Vir Biotechnology, are leaders in this space and are working on promising treatments. What’s more, the report notes that “Antibodies can protect healthy critical workers, as well as ‘high risk’ individuals.”(emphasis in original)
3) Vaccines. The report notes, “This third-wave, vaccine-based approach will establish long-term victory over the virus.” Which is exactly why America needs a Manhattan Project to develop a vaccine. There is promising news on a potential vaccine developed at Oxford that is proceeding to a 6,000-person trial. Pfizer’s CEO announced Tuesday that the company is spending $650 million preemptively to build manufacturing capacity for a vaccine it’s currently developing in order to supply millions of doses later this year. (Assuming the drug works.) Of course, there are no guarantees and the roadmap document estimates 2021 as a likely date for a vaccine.
4) Restoring Our Society and Economy. The re-opening plan is built around symptom certification, frequent testing, wide use of PPE, and widespread antibody (serological) testing. Once we reopen, we want to stay open and this is a way to do that. There are plenty of governors and mayors who would be more than willing to shut things down again even though shutdowns come with their own very real human and financial costs. This is a way to avoid that unhappy fate.
Although states are starting to reopen we must recognize that we have not yet won the war against COVID-19. With the information we now have, more people should recognize that there is a path that is somewhere between “it’s just the flu” on the one side and “millions of Americans are about to die” on the other. There are plenty of good faith, intellectually defensible positions in between and as more information comes to light we should adjust accordingly.
For now, the most constructive way for us to frame this pandemic is as an opportunity.
It’s an opportunity to develop new solutions to old problems. I’ve described a few ideas here. I’m sure there are many others. Deadly viruses have threatened mankind forever. This pandemic presently is catalyzing a response from scientists around the world on a scale never before seen with tools that didn’t exist even a decade ago. We don’t know what they will discover or when or to what use it will ultimately be put, but it’s hard to envision a scenario where all of that effort doesn’t produce unexpected benefits.
Everyone wants things to go back to the way they were before. In many ways I agree, but the virus itself and the response to it have exposed areas for improvement. And in those areas, let’s build something better. Let this be the moment we show that America is still capable of solving big problems.