The Hard Road Ahead

Fighting the Chinese coronavirus is important. That’s been my message for the past couple weeks: This is not the flu. We need social distancing or we’ll end up digging mass graves. I’ve been very focused (as have most of the experts I trust) on getting people to take the appropriate precautions now, leaving other questions to be answered later, when we had more data on the virus.

And, guys, we’ve been doing a okay job of it, altogether. There are always morons, but the schools are closed, parents are working from home, Domino’s Pizza won’t let you in the store unless there’s enough room for you to stand six feet apart… yes, we still need to tighten the cordon. We still need individuals to take it more seriously. But I’m proud of our nation’s decision to treat this disease like a serious threat before our hospital wards look like this… or this.

I want you to think about this for just a moment: since the dawn of civilization, plagues have killed staggering numbers of human beings. Individual communities have had some very basic self-defense tools, but, until recently, nobody knew enough about disease and how it spreads to do more than cancel the parade once the plague arrives. In the covid plague, for the first time in human history, we have a choice. We can choose to save lives, albeit at great cost to ourselves. I’ve written that COVID-19 could easily kill 3 million Americans, maybe 100 million people worldwide. That’s more people than died in World War II (including the Holocaust). But I’ve also written that, through collective action to slow and stop the disease, we could save most of those people.

And that is what we have collectively decided to do. We didn’t have to. We could have let those people die (mostly old people, after all) and kept the economy intact. But we opted to plunge ourselves into recession instead.

If your business is shut down, it’s for the sake of those hundred million people. If you had to cancel your wedding, you’re saving those lives. If you’re stuck in a hospital, unable to receive visitors in your hour of suffering, it’s because you’re trying to save more people than died in World War II. And, of course, if you’re a front-line health care worker, you are not only physically saving lives, but are putting yourself at risk, too. Personally, it’s been pretty easy for me so far, but the sacrifices some of you have made are stunning. You are Big Damn Heroes, and I am very proud to be able to share this planet with you. Thank you for everything you’re doing.

After 9/11, we (correctly) lionized the New York City Fire Department, which charged heedlessly into a burning building to save life and paid the price. The millions of you who are suffering in this crisis, for the sake of saving those lives, are this generation’s FDNY. And you have already saved literally tens of thousands of lives, with more saved every day through your social distancing. (And, who knows? The life you save may be your own.)

When we started social distancing, one key question we hadn’t answered yet was, “How long will this need to last before we go back to our normal lives? 2 weeks? 6 weeks? 12 weeks?”

Another, related question was, “What’s our strategy to get through this?” Lots of people talked about “flattening the curve,” spreading out the coronavirus patients so our health care system doesn’t get overwhelmed. This strategy is called “mitigation.” But others spoke of crushing the curve, where we ended the infection totally, as quickly as possible, no matter the cost, so we could go back to living regular lives sooner. This strategy is called “suppression.”

At the time, the answers to those questions didn’t really matter. Whether our long-term strategy was going to be mitigation or suppression, any response to covid (besides “let millions die”) had to start with a lockdown like the one we’re living through now. Transmission had to slow down enough for us to get our footing. We would figure out plans for the next month and the next year only after we were sure our hospitals weren’t going to collapse in the next week.

Well, we did that. Although it will take weeks to see the results, because of the coronavirus’s long incubation period and our country’s very bad testing, we should soon start seeing the pace of new infections slow, then fall. So what’s the next step?

By now, you’re probably aware that Imperial College London has a terrifying answer to that question. In a blockbuster paper published early this week, their blue-ribbon COVID-19 Response Team explained that a mitigation strategy was doomed to failure. The hospital system would still exceed its maximum capacity by a factor of eight. Over a million people would die in America alone. Many others would die of non-covid treatable illnesses because we would no longer have a medical system to care for them. Not as bad as doing nothing, but still unacceptable. Mitigation and “flattening the curve” don’t work.

The Imperial College thought that a suppression strategy would work, though. Heavy lockdown would keep Wuhan coronavirus infections at a very manageable level, and we could even relax suppression measures from time to time and go back to normal life for a week or two. We would only need to maintain a suppression strategy until worldwide deployment of a working vaccine…

…in 18 to 24 months.

According to the Imperial College model, if we drop suppression measures before the vaccine, the disease surges back. Our hospitals are overwhelmed, and tens of millions of people die, including millions of Americans. (The Imperial College paper predicts shockingly large death tolls, but these are actually lowball estimates, because the Imperial College did not take into account how the collapse of our hospital system would increase fatality rates.) That means 18 months of this global paralysis, of lockdown. Some wrote about what that could mean.

I didn’t. When I read the Imperial College report, my stomach dropped, and I stopped writing about covid for a few days.

Why? Because it’s impossible. We can’t do it. Two weeks of partial lockdown have plunged us into a severe recession. Essential services, like the supply chains that keep my grocery store stocked, are visibly faltering. Less essential services, like haircuts, are totally inaccessible. Months of this will spell depression. Years? That’s a civilization-ending event.

Reader, if the Imperial College is right, if our choice is between 18 months of lockdown and 100 million deaths, it doesn’t matter how much we want to make the heroic choice: those people are going to die. Some of them could be people I love. One of them could be me. It doesn’t matter: I do not believe our economy has the werewithal to do this for a year and a half without civil unrest, famine, and starvation.

I stopped writing because I didn’t want to share my despair with you.

But I’ve had a couple days to think about it now, and I think despair is unjustified. The stark choice presented by the Imperial College paper does not represent all the possibilities. It only represents all the possibilities available to us today.

Right now, we’re in varying levels of lockdown. The Chinese coronavirus has been slowed. We are all doing our parts to #BendTheCurve. That doesn’t end the crisis. We’re not all going back to work in two weeks with this all behind us. The worst is, in fact, still ahead.

But all our efforts right now are buying us time. If citizens and state governments take the lockdowns seriously, we probably aren’t going to see the entire U.S. medical system collapse in the next couple weeks, which is the path we were on just days ago. We can hold the virus in stasis (more or less) for a while… which means we can now focus our resources on finding an acceptable solution. We don’t have one yet, but we have many promising leads.

Like what, James?

Well…

We could develop a treatment! A vaccine is still at least a year away, but there are lots of treatments out there for different viruses. One of them might work on covid. If that happened, it could bring the fatality rate down to an acceptable number — maybe a couple hundred thousand Americans, rather than a few million. That would still be nightmarish, but it would be tolerable — and it would keep our hospitals functional.

There are lots of potential covid treatments to explore. Some scientists are looking into treatment with antiretrovirals normally used against HIV. Some are still working on corticosteroids, although early data was disappointing. You’ve probably heard about the promising outlook for anti-malaria drugs, still in trial. There’s an anti-MERS drug that we’re trying called remdesivir (and, if it works, we’ll all have to learn to spell that). MERS, remember, was also a coronavirus, so I’m pretty hopeful about remdesivir.

There are a dozen other treatments being explored right now, with brand-new, tailor-made antivirals in development across the world. Thank free markets for that: there is a lot of money to be made by whoever makes the cheapest anti-covid drug, and every drug company in the world wants a piece of it.

Disease science is a grim place. The vast majority of these trials will either fail or show disappointing results. (That’s why the drugs that do work are so often so expensive.) While we could have some results by late April, others are months away.

But we only need one treatment for covid. If we get one, and it’s effective enough to bring covid’s fatality rate down to “flu pandemic” levels, then we can end the lockdown and go back to something like normal life.

We could get lucky! There is still so, so much we don’t know about China’s coronavirus. Does it die off in summer? We don’t know. That could buy us a few months lockdown-free while we fortify ourselves for the coming battle in winter.

We know covid doesn’t cause many children to experience severe symptoms, but do children transmit it as efficiently as adults? Believe it or not, we still don’t know. If it turns out that children aren’t very good disease vectors for this coronavirus, we could potentially reopen the schools, easing many problems.

We are still having a very hard time nailing down exactly what covid’s “natural” fatality rate is (in a non-overwhelmed hospital system), and there is still a surprising amount of uncertainty about how viral it is (its “basic reproductive number”). Some even question basic assumptions about how long the coronavirus’s exponential growth will continue. If covid turned out to be less fatal or less transmissible than currently believed–a faint hope, but a plausible one!–we may find that the lockdown was an unnecessary overreaction all along.

Wouldn’t that be fantastic?

We could test the hell out of everyone! This seems to me like the most plausible way out. It’s based on existing technology, and it seems to be what most of the experts I respect most are thinking about. That’s not surprising, because it’s what South Korea and Singapore both seem to be doing… and it seems to be working.

Here’s the idea in a nutshell: we start out with a standard suppression strategy. We lock everything down for a while, long enough to slow the virus’s spread to a trickle. Then, we lift the lockdown. However, this time, instead of letting the coronavirus spread freely until our hospitals are again overwhelmed, we test everyone, constantly.

When you go to work, you’re not allowed in the door until you’ve had a temperature check to verify no fever. When you show the slightest symptoms of anything, you are immediately tested and sent to quarantine until the results come back. Drive-up testing is universal and free.

We catch infected people the instant they start showing symptoms, and we quarantine them. Then we aggressively track down everyone they’ve had recent contact with (this is known as “contact tracing”), and we quarantine them, too. Quarantines are not voluntary and self-monitored, as they usually are in the United States today. Quarantines are mandatory, administered by the local constabulary, and violations are punishable by fines and jail.

With these tools, we can shift back from “mitigation” and “suppression” to the original strategy from February: “containment.” In containment, we know there’s a few people who have the disease, but we know exactly who they are, we keep them from spreading it, we aggressively seek out any cases that may have gotten past us, and the result is we avoid another round of exponential spread.

We can’t do this right now, because there are 20,000 known infections, almost certainly more than 100,000 actual infections, and millions of people who’ve been in close contact with the infected. There are no resources to track down all these people and quarantine them, even if we had tested them, which we haven’t.

Speaking of which, we also can’t do this right now because we don’t have the tests. America fell massively behind in February due to severe technical and bureaucratic errors at the CDC, and we will never catch up as long as the epidemic is growing exponentially. (That’s a big reason why containment failed the first time.) The PCR tests we have are slow, we can’t run them fast enough to keep ahead of demand, and we’re now running out of supplies. Minnesota is rationing tests, openly telling people who think they have it but aren’t dying to just stay home and try to get better. That approach is absolutely incompatible with the “test everyone” regime. But it’s the only approach possible right now, given our low testing capacity.

But in, say, three to five months? (Imperial College said five months.)

By then, our suppression strategy should be a clear success. The hospitals should be through the worst of this first wave. Thanks to all the social distancing we’re doing now, that wave should be less dire than I predicted last week. Our hospitals should get through it more or less intact. Cases should be back down to a manageable level.

And, if we start now, we should be able to fix our testing problems by then. We should be able to ramp up production on test supplies. We should be able to build out more capacity for testing. We should be able to augment our current PCR tests with fast, cheap, very useful serology tests. There are hundreds of labs working to make a test you can take at home for a dollar–and some are hopeful of a breakthrough within three months. There are now, quite suddenly, millions of unemployed Americans, many of whom could be hired as contact tracers.

If we can get the United States’ testing capacity up to around 100,000 tests per day (the same as South Korea’s, adjusted for population), push our case count down to maybe 400 new cases per day (again, that’s where South Korea is today, adjusted for population), and get everyone on board with aggressive monitoring strategies, then we could (presumably) lift the lockdown and switch to this “containment” strategy.

Life would not go back to normal–this really is going to last until we have a vaccine, which is almost certainly a year or more away–but life would go back to something pretty close to normal for the vast majority of us.

So we can’t do a South Korea containment strategy yet, but, even if all the potential treatments fall short, we should be able to do one after a few more months of social distancing.

If you want to hear this plan from a real epidemiologist, read Trevor Bedford’s thread about the way forward, or Adam Kuharski’s little infographic about the same thing. If you want to read a more formal treatment of this plan, using math and stuff, take a look at Chen Shen et. al.’s review of the Imperial College paper.

This is doable. However we get out of this trap, it’s not going to be easy. We’re still going to have a lot of heroes at the end of this, and I fervently wish we didn’t need them. I really don’t know when baseball or public worship is coming back, nor do I think international borders will start opening up again any time soon. But we’ll be able to go to work. We’ll be able to see our friends. We’ll be able to shop in the stores. We’ll be able to go to confession.

The bottom line is, we can get through this. There are many approaches we are taking to try to get COVID-19 under control, and lots of them are promising. Keep the faith, do what you can, and we’ll get through this.

Time to put your money where your mouth is, James. What does all this actually mean, on a practical level? WHEN will life go back to normal? WHAT are the next few months going to look like?

Okay, with the very big caveat that I am not an epidemiologist or even a real scientist, here’s my personal read of the situation. I make no guarantees. Last week, when I was simply describing exponential growth and applying simple math formulas, I was on firm ground. Here, I’m beyond my expertise. I know there are some actual medical professionals who read this blog; I invite their corrections and their doubts, and I will update this post with them if I get any. But here’s where I think we’re headed.

One way or another, it seems to me that we will be able to get out of full “social isolation mode” this summer. Maybe as early as June, maybe as late as August, but we are going to get this infection under control, we are going to get our testing capacity up, and we may even find a treatment. If we’re lucky or clever, we might get out of this even earlier. I would not be shocked to see life returning to normal-ish by mid-May… but I’m not counting on it, either.

Over the next month or two, there are going to be quite a few deaths. If the United States doen’t pass 200,000 diagnosed cases nationwide by April 1st, we will be very, very, very lucky. Worse, since our testing is so poor, 200,000 diagnosed cases is likely closer to 2 million cases nationwide, with nearly 1% of Americans infected. If that’s true, then, by May 1st, we can reasonably expect 10,000-20,000 people to be dead of the coronavirus. That’s bad, but keep it in perspective: a bad flu season infects 50 million and kills 50,000. The Chinese coronavirus will push our medical system to its limit, but it won’t collapse. And, if our social distancing measures to date have been enough (and I pray they have been), then early April should be our peak.

For the time being, it is imperative that our social isolation continues. Otherwise, we will never get to the point where we can safely lift it. Since the U.S. is a big country, with several different epidemics in progress in different places right now, there may be some local variability in what controls are necessary. But these basic rules should hold for everyone for at least the next couple of months: Don’t gather in groups larger than 10 people. Work from home if you possibly can. Schools need to remain shuttered for now, likely for the rest of the school year. Don’t fly. Be paranoid about your fevers and coughs–and equally paranoid about the fevers and coughs of those around you. Be a little scared: it’s healthy, and it might keep you alive.

Support the economy however you can, if you’re in a position to do so. Order delivery, take-out, or drive-through, even more often than you ordinarily eat out. So many stores are closed to foot traffic right now, but try to order goods from them anyway–and I mean the Red Balloon Bookstore down the road from your house, not Amazon.com. They might be able to limp through to summer that way.

There’s no disguising the fact that three or four months of this will be hell for our economy. But we’re saving millions of our countrymen, and tens of millions of people around the world. That seems worth a deep recession to me. It looks like the United States Mint stands ready to print its way out of economic trouble. If there has ever been a time to cut every American a nice fat check — quite possibly several checks, over several months — this is it. We can deal with the fiscal fallout later. (Coming 2021: tax hikes!)

Meanwhile, what you want to be looking for is testing breakthroughs (and, if you’re feeling a little optimistic, clinical drug trials). Some people on Twitter are saying that testing doesn’t matter anymore, because containment has failed. They’re right, in a way: containment has failed. The first wave of deaths is coming, and there is no longer a single thing we can do to stop it.

But South Korea and other Asian nations show that we can get back to a containment posture once our case loads are down and we have extensive testing. That should be our aim now.

Our decision to take the novel coronavirus on directly like this is without precedent in human history. Every other generation since the rise of civilization would simply have lost 100 million people, because they wouldn’t have had a choice. The choice itself is terrible, but I’m glad that we have it, and I’m proud of us–of you–for choosing to shoulder the costs of saving those lives. You may not hear this enough in the coming days, so let me say it now: thank you. You’re my hero.