Containment or Bust

Flattening The Curve Is Not Enough – Containment Is The Only Non-Catastrophic Option

 

There’s been a lot of talk about “flattening the curve”, reducing the rate of infections so that hospitals can give every case the treatment that is required. Yet if we believe the attack rates of 60 to 80 percent estimated by experts as well as the fraction of 20% as the number of patients that require hospital care, quoted in the WHO report along with the 3-6 week recovery time – then allowing the virus to “burn through” the population at any rate is disastrous.

In a business as usual scenario, the number of COVID-19 cases seem to double, roughly every 4 to 5 days. Since critical cases take 3-6 weeks to recover, then to “flatten the curve” enough to allow a significant reuse of hospital capacity for new cases, as previous cases recover, you would really need to extend the doubling time from 4 or 5 days – out to 3 or 4 months. To drastically reduce R0 enough to lengthen the doubling time from 4 or 5 days to 3 or 4 months (the minimum period to achieve substantial recycling of medical equipment) would require extreme non-pharmaceutical interventions.

This raises the question: If we are going to take extreme measures to drastically reduce the R0 of COVID-19, why not go those extra few yards and really try and push the R0 of the virus below 1, so that the majority of people never have to get infected?

But even flattening the curve out for 3 or 4 months isn’t enough. On the 12th March Lombardy had 8,725 cases and already the hospitals there were overwhelmed. If we assumed Lombardy’s hospitals have the capacity to deal with the intensive care patients that are produced by 8,725 cases from COVID-19 (which they clearly aren’t) then, given the population of the Lombardy region is 10 million, and assuming each intensive care patient requires 3 weeks of care, in order to “manageably burn through” all the COVID-19 cases in Lombardy, there could only be 8,725 new COVID-19 infections every 3 weeks. This means, assuming, 6 million people in Lomabardy end up catching it, COVID-19 would need to take at least 2,063 weeks to burn through the population of Lomabardy in order to be manageably handled by the hospitals and ensure that every serious patient is adequately cared for. That’s about 40 years!!!!

Joscha Bach has written an article that elaborates this point in detail.

A peer reviewed quantitative analysis by Imperial College has also arrived at the conclusion that, even during a flattened curve scenario, hospitals will be completely overwhelmed.

In order to “flatten the curve” enough for COVID-19 to take 40 years to “manageably infect” the entire population of the world, its R0 would have to be reduced from about 3 to a hair’s breadth higher than 1.

And if we are going to go to all the hassle of changing the way we do things to bring the R0 of COVID-19 all the way down from 3 to 1, we may as well put in the extra effort to push it below 1, and properly contain it, so that cases cycle down to zero and only a small fraction of the population get infected.

For all these reasons, “flattening the curve” is not an acceptable outcome, we must either contain COVID-19, or face catastrophe.

There are six stages of awareness:

1. Denial
2. Anger
3. Bargaining
4. Fear
5. Depression
6. Acceptance

The belief that “all we need to do is flatten the curve, then our hospitals will be able to successfully treat all the cases” is a part of the irrational bargaining phase. It’s the idea that we won’t have to be as strict as China, we won’t need lockdowns, mass quarantines, and masks, we just need to wash our hands a bit, and give people few few elbow bumps so the disease progresses sufficiently slowly through the population to enable our hospitals to cope and then everything will more or less be fine.

Unfortunately the numbers in both Italy and China do not support this view. COVID-19 overloads healthcare systems even when a tiny fraction, less than 0.1%, of the regional population gets infected, due to the intense, expensive, treatments required by serious COVID-19 patients which utilize scarce resources. There is no way to “manageably infect” 80% of the nation with COVID-19 – on any remotely realistic timescale.

Right now most people are in denial. We are constantly reassured that most cases are “mild.” It’s worth mentioning that “mild” means fever and possibly recoverable pneumonia, while “severe” and “critical” means likely death without medical attention.

If you feel reassured by an 80% chance that you won’t require urgent medical attention in the next few months, I’ve got a game you might enjoy playing: it’s called Russian Roullette.

Furthermore, the mortality rate of 1-2% is with medical attention. If the hospiitals get overloaded the death rate will likely be higher. This article conservatively estimates, after looking at several real world examples of existing health systems that were overwhelmed, that about 4% of people who catch it will die. And if 70% of the total world’s population get infected by COVID-19, as some experts estimate, then 2.8% of the world’s population will be killed by COVID-19 in the absence of containment.

To put that in perspective, 3.55% of the world’s population were killed during the 6 years of World War II.

Unless we can contain COVID-19, it will kill a similar fraction of people, over the next few months, as World War II killed over the course of 6 years.

And since the disease is brand new, we don’t yet know how long those who recover from it will remain immune. It’s not inconceivable that, in the absence of containment, new strains will emerge every year or two and take out another 3% of the world’s population every couple of years (well, given people will likely have some immunity it might be closer to 0.5-1% in subsequent years).

It’s also worth mentioning that there is no assurance that a vaccine will be available in 18 months. 18 months is quoted as the absolute minimum timeframe that a vaccine could be made available to the general public, but as Dr. Bruce Aylward pointed out in a press conference, we are really bad at making vacines that are effective against coronaviruses. There’s currently no safe and effective vaccine for SARS, MERS or the common cold. So, pessimistically, a vaccine could easily be as long as a decade away.

Since:

1. “Flattening the curve” to keep COVID-19 cases at a level hospitals can cope with is no easier than containment
2. A vaccine may be up to a decade away

Containment, hard though it may be, might be the only way to avoid suffering the same kind of yearly death count that people suffered through during world war 2, year after year, as new strains of this deadly version of the common cold come back to sweep across the world, slaughtering the elderly in their wake, over and over again for the next decade.

Even a single wave of COVID-19 could knock out 10-30% of the those in their late career and early retirement (in a scenario where hospitals get overloaded), and if we sustain subsequent yearly waves of slightly different strains of this disease, each subsequent wave might pick off another 5-10% of those who are retired or approaching retirement.

In a previous article I wrote, I explained how the loss of the elder generation would have a disastrous impact on the whole economy due to the role which older members of society play in both organizing our social institutions and there disproportionately high role in industries lower down Maslow’s hierarchy of needs which produce the necessities of life and sustains necessary infrastructure.

This plague will not just “go away on it’s own.” It will not go away unless we make it go away.

The sooner we face this stark reality, the less people will die.

 

Containing COVID-19 Will Be Incredibly Difficult – And Will Require Absolute Determination

 

COVID-19 is more infectious than the flu. This should gives us some idea of how difficult it will be to contain.

Indeed, the only reason for us to hold out any hope that COVID-19 may be contained is the fact that it is sufficiently deadly to induce massive behavioural changes in people seeking to avoid it – unlike flus and colds.

Endemic diseases, such as smallpox, have been contained in the past. And it’s worth mentioning that the R0 of smallpox is larger than that of COVID-19 so, with sufficient will, the containment of COVID-19, should in theory still be possible.

Quarantine and drastic social distancing has an equivalent effect to vaccination.

The big difference between COVID-19 and smallpox is that there is a vaccine for smallpox while there is no vaccine for COVID-19. And quarantine is far more economically expensive than vaccination. On the plus side, remote communication technology and data analysis have never been more advanced.

I think a lot of politicians and business men, who think that “we simply can’t afford to bring our economy to a standstill in order to contain this virus”, have not really thought through what 4% of their country’s population dying (and especially, once the hospitals fail, what 10-20% of people in their late careers dying including politicians, celebrities, CEOs, court judges, nuclear power plant engineers, etc.,) over the course of a few months, actually looks like in real life.

At some point, things will get so bad, that the leaders of our nations (assuming they haven’t died of COVID-19) will be forced to take all the extreme measures they were previously afraid would harm the economy, anyway, and – since the number of infected will be much larger – they will be forced to implement these containment measure on a wider scale, over a more protracted period, and do more economic harm, than would have occurred if they had implemented them earlier on.

Sooner or later, when they see the unacceptable, horrific effects of this killer virus ripping through the country, and the widespread devastation it reeks on real people and real families, politicians will, sooner or later, take extreme measures in an attempt to contain it – when it really hits us hard in a months or two, there will be no other alternative.

One way or another, the economy is screwed.

Our only choice at this point is: do we want to damage the economy earlier on, and damage it less, or damage it later on, and damage it far more?

And I might add, that there is no reason to believe that once COVID-19 infects the entire population, it will be “over and done with.” This again, is just another example of a hope that we are clinging onto and repeating as a mantra in order to avoid a sense of absolute despair… a hope that may not be true. The more people COVID-19 infects, the more the virus will evolve and diverge into a menagerie of different strains. And even after everyone gets infected once, new strains could infect – and kill – people over and over again, year after year. This wouldn’t be unprecedented, the black death continuously killed people in large numbers over a period of 4 years straight from 1347 to 1351. For 3 years straight, between 1862-1864 a plague of smallpox infected the Haida population over and over again and eventually killed 90% of them.

We don’t need hope. We need ACTION!

We NEED containment.

We might not succeed. But this is no reason not to try. This is no reason not to throw everything we have into trying to contain this rapidly developing plague.

If COVID-19 spreads uncontrollably, the number of people it will kill per capita will be comparable to the number killed during the bloodiest war in the 20^th century. A total of 200 million people are likely to die within a matter of months, that’s 20 times the number of people who were killed during the holocaust – if new strains evolve and continue to infect us year-on-year, maybe more. Today the number of deaths outside China continues to climb exponentially, increasing 10-fold every 2 weeks; 100-fold every month. And yet politicians, and the general public of many countries, seem resigned to allowing this virus to overcome their respective nation’s. Imagine if a foreign army invaded the borders of your nation and, when the leader of your nation spoke to you, he said the following:

“Because it will be very hard to stop this invading army – and because resisting would interfere too much with your lifestyles – we have decide to bargain a delayed surrender with our foe. By surrendering in this way, we will the flatten out the invasion and ensure it occurs gradually, in a more managed way, rather than suddenly. Oh, and by the way, don’t worry, the general of the enemy army has promised he won’t torture 80% of you by filling your lungs with water for 3 to 6 weeks, and even if you are one of the unlucky one’s who get tortured, there’s at least an 80% chance you won’t die on average. Indeed, as an added incentive for those of fighting age to capitulate peacefully, the invading horde has promised to torture and kill less than 1 in 100 of you, and will mainly focus on butchering 1 in 5 of your parents and elders. So there’s really no reason to worry, no cause for alarm at all. The most important thing is that we cheerily accept this invasion, look on the bright side, and above all, don’t panic.”

What would we think of a leader who gave his people such a speech during a time of crisis? What opinion would we have of a people who meekly accepted such a fate?

However, because COVID-19 is incredibly infectious, we only have a chance of containing it by simultaneously throwing everything we have at it.

 

Throwing Everything At Containing COVID-19

 

There are four things that can slow down the spread of COVID-19:

• Early detection and quarantine
• Social Distancing, Hygiene and PPE
• Strategic closure of borders
• Hot weather

The number of confirmed cases in hot equatorial countries, and countries South of the equator, seem to be growing more slowly than than the number of confirmed cases in medium and high latitudes north of the equator. This paper seems to espouse the hypothesis that there is a narrow band of temperatures and humidities in which COVID-19 can rapidly spread. Given the exploding cases in Norway, Sweden and Denmark, I’m not convinced of the low temperature limit. But there does seem to be a fairly consistent trend of COVID-19 cases growing more slowly in countries where the temperature is higher.

I must emphasis that temperature only seems to slow the rate of growth temperature alone will not push the number of into decline (as we can see from the fact that case numbers are steadily growing in hotter climates – just more slowly) unless it is accompanied by other, aggressive measures to reduce the virus’s rate of spread.

The active measures that we can deploy to push the virus into decline are:

• Test everyone with a fever for COVID-19
• Test everyone who contacted someone else who tested positive for COVID-19 within the last 2 weeks
• Quarantine all positive cases, and all contacts of positive cases, until they test negative
• Foster a National Ethic of social distancing and general hygiene, at an individual and institutional level, as a matter of Civic Duty
• Evaluate the R0 of every institution in the country (company, charity, municipal government office, etc., etc.,) and order the mandatory closure of every unnecessary institution whose R0 exceeds 1 (in the event that one COVID-19 case is found)
• Ensure that no households contain cohabitants that commute to two or more separate workplaces, for the duration of the pandemic
• Concentrate PPE on necessary workers in jobs that are potentially major vectors of spread (in the absence of PPE and appropriate training)
• Continue to aggressively develop better COVID-19 tests which:
  • Require less skill to operate
  • Give faster results
  • Give more reliable results
  • Are cheaper and easier to mass produce
  • …and import the state of the art tests from whatever producers are the market leaders in this respect

• Mobilise national effort to increase PPE production

• Test 1-in-100 people who enter the country for COVID-19, force every traveller from any country that yields a positive test, to pay to have themselves tested for COVID-19 as a condition of entry and close the border with any country where more than 1 entrant in 1000 tests positive for COVID-19
• Train armies of volunteers to:
  • Test people for COVID-19
  • Contact trace
  • Manufacture PPE
  • Deliver necessary good to facilitate social distancing and reduce crowding in shops (i.e. the timely delivery of food supplies to one’s door)
• Ensure a sufficient stay-at-home allowance for:
  • Everyone who is quarantined
  • Everyone whose job is unnecessary, and whose workplace has an empirically measured R0 greater than one and who cannot reasonably work from home
  • Whose skill set and career choice is most suited to applying for unnecessary jobs that would tend to spread the outbreak
  • Is sick with a mild case of COVID-19
• Give people the option to join “closed pandemic households.” Some people are happy living alone, others become desperately lonely. For those who live alone but get lonely without human contact, facilitate the formation of “closed pandemic households”, households of people who live together (but perhaps would otherwise live alone) who interact freely with each other, but don’t physically interact with anyone else outside the household – closed pandemic households must not exceed 5 members – members of the household must ensure that they, and every other member, does not expose themselves to any risk of infection.
• Ensure that the process of transporting people into a closed pandemic household is secure and involves a very low risk of infection for both the driver, and the passenger (where both driver and passenger have self-isolated for 2 weeks and tested negative for COVID-19 and that the car has been wiped down with bleach etc., etc.,) 

What all these measures contribute to is to:

1. Reduce the spread of the disease by infected individuals per unit time (social distancing, hand hygiene, use of masks, gloves, PPE, disinfecting surfaces, opening windows to disperse any viruses in aerosol form, lowering the lid on toilets before flushing, drying hands with disposable paper rather than using blow dryer to avoid aerosolizing any virus on hands)

2. Reducing the time infected individuals can spread the virus (Early detection and quarantine)

Imagine a weed that grows in the soil and produces seeds from which other weeds grow. The less fertile the soil; the slower it grows. Social distancing is like lowering the fertility of the soil. Detection and quarantine is like a team of gardeners which wander around the plot rooting out weeds as well picking the seeds dispersed by those weeds.

It’s now worth elaborating on some of these measures.

 

What Does Social Distancing Mean?

 

Social distancing means minimising your interactions between everyone outside of a fixed household of people where each person in the household also minimises their interaction with others outside of the household. If there is one weak link in the household, one member of the household, who does not minimise their interactions with people outside the household then the ENTIRE HOUSEHOLD is likely to get infected.

The only interactions that may be necessary with those outside a household is:

1. Necessary work that cannot be conducted without leaving the household
2. Collecting delivered goods

If no one has necessary work which they must perform outside the household, then, so long as everyone remains in the house or in the garden, and no one leaves and exposes themselves – and, consequently, the entire household to contamination – then, for the most part, everyone can relax, and collecting delivered goods is only activity that involves any risk.

• All the surfaces of delivered goods should be wiped down with bleach
• Ideally delivery-men should drop the goods outside the door and then leave. Confirmation of receipt should be conducted by phone or some kind of remote messaging system, signing on receipt should be eliminated
• All the surfaces of delivered goods should be wiped down with bleach
• Delivered goods should be taken to a specially allocated decontamination room (or decontamination cupboard) and left there for 10 days, as coronaviruses can remain activated (alive) on surfaces outside the body for that long.
• After carrying goods to decontamination room, gloves should be dipped in bleach
• All surfaces touched by gloves while moving the package to the decontamination room should be wiped down
• Possibly wipe down path walked to decontamination room, or lay newspaper, or something else, along this path which can then be disposed of or put in a washing machine
• Better to buy in bulk and infrequently, than order small frequent deliveries

When taking out the trash, gloves and homemade masks should be worn, gloves should be dipped in bleach after re-entering house, soles of shoes should be dipped in bleech outer clothing should be washed.

If nobody in the household goes out to work, staying uninfected should really be that simple.

Dr. John Campell has made many Youtube video where he has discussed general hygiene and social distancing at length along with many issues surrounding the COVID-19 outbreak

If an individual must go outside to perform necessary work, that individual should either:

1. Ideally Live alone
2. Live in a household where no one else works
3. Live in a household where all the inhabitants work in the same workplace

If more than one household member works and each member works at a different workplace, that living arrangement opens up a workplace – household – workplace – household chain of transmission where different workplaces can be infected through the path of co-habiting households.

Essential workers that share a household with someone else who goes out to work should consider changing their living arrangements to either live alone, or move in with someone who works in the same work place, for the duration of the pandemic.

While working, workers who do not share the same household, should stay a few meters away from each other unless the nature of their work specifically demands otherwise. If there is a relatively low risk of infection workers should wear:

1. Plastic Gloves (unless the job calls for delicate finger work) which are washed frequently, and in the case of delicate fingerwork that requires the absence of gloves, to wash your hands frequently
2. Homemade facemasks ( Effective at reducing the degree that infected individuals are contagious to others – since people can spread the virus before they know they are infected, everyone should wear a homemade face mask)

If the risk is high, more PPE should be used as appropriate.

Workers should avoid public transport and, if possible, travel to work by car. If said worker does not own a car, then said worker should get regularly get a lift with the same co-worker everyday.

The workplace should be run in a similar manner to the household in the sense of minimizing contact with outsiders. Extra care should be given to interactions with both customers and suppliers. Avoid and minimize personal interactions between both customers and suppliers, if possible, as these (in addition to publiic transport) are routes whereby infections can enter your workplace.

Sick employees with COVID-19-like symptoms should immediately self-isolate, be tested for COVID-19, and be given sick pay.

When coming back from work, and re-entering the household, the soles of your shoes should be dipped in bleach and then taken off. Your gloves should be dipped in bleach, then used to removed your outer clothing, which should be immediately washed.

If at all possible, do not carry your smartphone outside your household, if you need to as part of work, disinfect it with a disinfectant wipe.

If one or more members of a household works, then unlike a situation where the entire household is fully isolated, the other members of the household would be advised to keep a distance, wear masks and disinfect surfaces in the house regularly.

Does all this sound hard?

If it does, consider this: Just over a century ago, people were prepared to spend 4 years in the trenches, up to their knees in mud, getting shot at, shelled and attacked with poison gas, tormented by rats and lice where they developed trench-foot and frostbite which for many, required amputations.

What would the soldiers of past generations, who sacrificed their lives in war to protect their countrymen, think of us if we fail to rise to this challenge? What would the soldiers of World War 1 and previous generations think of us if, by failing to act, we allow millions of our fellow countrymen to die, and release a plague upon the world that could revisit us for years to come, just because staying at home for four months or so in a well-heated suburban house with running water, home entertainment systems and plentiful food delivered to our door was “too large a sacrifice” for us to make???

 

Social Distancing As A Civic Duty

 

When case numbers are low, either at the start of an epidemic, or at the end of a successful containment effort, the chances of any one person catching the disease is minimal so, from the point of view of self-protection, any one person is fairly safe without engaging in social distacing or taking precautions.

But here is the important point:

Precautions, during an epidemic, are not solely to protect oneself, they are to protect society.

When you stay at home and don’t contact people with the exception of economically necessary work, if you wear a mask, if you disinfect surfaces, then you are contributing to reduce the R0 of the virus throughout the population. If everyone does their bit, and practices social distancing, the R0 of the entire society will be much lower.

With a lower R0:

• Clusters, once detected, will be smaller and more manageable
• If everyone has less contacts, this will make contact tracing much easier and much more straightforward

For this reason, at the early stages of a pandemic, self-isolation, wearing masks and gloves, generally keeping a distance from people can be regarded as a civic virtue, even if the chances of getting infected are less than 1 in a million, every person who isolates, distances, or practices good hygiene contributes to making quarantine and containment that much simpler, easier and more probable – so long as they continue to perform any economically necessary role that is associated with their careers.

Large concentrations of virus particles have been measured in asymptomatic individuals there are good reasons to believe that those infected with COVID-19 may be contagious long before (1-14 days) they have symptoms. And even longer before those symptoms become extreme enough to be clear that its not a normal flu.

So because we can’t know who is contagious, the only way for society as a whole to slow the contagion down is for the entire poplation in a region, where an outbreak is discovered, to practice social distancing – the instant 1 person is found to have the COVID-19 virus. Even if only 1 person in a million carries the virus during a local outbreak, in order to slow the infection rate and contain the outbreak, the full million out of a million must immediately do their bit and start practicing social distancing. Not to protect themselves – but to protect society, because we know that while the chances of infection today may be one in a million. If we don’t all socially distance ourselves and practice hygiene today, the chance of getting infected by this potentially deadly virus and transmitting it to our loved ones will grow exponentially as time passes.

At this stage, COVID-19 can only be contained in non-authoritarian countries if everyone practices social distancing to the maximum extent possible.

In all honesty, the social distancing I described in the previous section is pretty extreme. And if everyone, uniform practiced a lower standard of social distancing and hygiene, then it would still probably be possible to contain the virus.

The problem is there will always be some irresponsible idiots out there. So if we want to successfully contain the virus, the rest of us will have to take extra-extreme measures to ensure that the aggregate R0 of society – idiots included – is less than 1.

Large scale compliance with voluntary social distancing, and both encouraging others to practice it and reprimanding those who don’t in the informal civil sphere, are both essential in order for non-authoritarian societies to protect their freedoms. The right to life, is obviously more important than the freedom to roam around and do what you want. And if it is necessary to pass draconian legislation to save lives, then so be it. But if everyone voluntarily cooperates and does their duty, we can contain the virus without the need to pass authoritarian legislation, which, once on the books is often difficult to remove.

 

Face Masks?

 

There is some controversy about average people wearing masks outside. This is due to the fact that many countries currently have an insufficient stock of masks and the governments of many countries have discouraged citizens from wearing surgical masks for fear that health-workers might not have access to them.

Masks have been shown to reduce people’s likelihood of catching the flu by 80% when accompanied by hand washing. However this experiment didn’t include a control group who just washed their hands without using a mask, so it may be that washing hands without a mask may offer the same protection.

However, it is generally accepted that face masks are effective at reducing the extent to which you are contagious to others. The CDC in the U.S. advises that sick members of a household be equipped with face masks to reduce their chances of infecting the healthy members.

So if everyone wore a surgical mask, then everyone would be more protected, although that protection would come primarily in the form of people who are incubating the disease unknowingly infecting others less by wearing masks as opposed to people who wear masks catching it less (a normal face mask does not significantly protect the wearer – while a respirator makes breathing more difficult).

The big issue with wearing face masks is that stocks are low and must be conserved for hospitals and the like. For that reason, purchasing commercially available facemasks, at this stage, does not aid the COVID-19 containment effort.

However, it is actually quite easy to make your own face mask from common, readily available, household items, here is a good video with clear instructions on how to do this.

It is also important to know how to hygienically put on and remove your face mask, as there is a right way to do this which prevent infection and wrong ways to do it that increase the risk of infection. This one-and-a-half-minute-long video tells you how to do it the right way.

Homemade face masks will both reduce the transmissivity of people who unknowingly carry COVID-19, without consuming valuable commercial facemask supplies. So wearing a homemade face mask if you have to be in a public place does contribute to the overall containment effort.

Strict social distancing and staying at home is massively more effective, and face masks should not be viewed as an alternative to social distancing, nor should they be regarded as making the wearer immune from infection (they don’t) instead they should be used in the context of economically necessary activities that require physical proximity to other people or the use of shared spaces.

 

Massive Testing And Quarantine

 

Quarantining everyone who test positive for COVID-19 at the earliest possible occasion is the surest way to reduce the spread of this disese. Testing the entire population of a country on a weekly basis for COVID-19, is impactical. However, according to the WHO report 87.9% of patients with COVID-19 develop a fever. Thus, given that clusters of infections contain many individuals, if everyone in the country that developed a fever was tested for COVID-19 then every COVID-19 infection cluster across the entire country could be identified within about 2 weeks.

The problem here is that people are infectious before they develop fevers. However, by combining the comprehensive testing of everyone with a fever, as a means of identifying the infection clusters with contact tracing and the testing all the other contacts, all the members of the cluster can be quarantined promptly. Hopefully, as testing procedures become better and better, it will be possible to ascertain whether people are infected before they are contagious.

If this approach is combined with the ubiquitous recognition by every member of the community that social distancing is a civic duty (even when the risk of infection to any one individual is very low), clusters will be smaller, contact tracing will be simpler and easier, and it should be possible to contain every one of the outbreak clusters. If the testing methods are not sufficiently well-developed to deliver a reliable positive result prior to an individual becoming infectious, it may be necessary to quarantine all contacts for at least a few days until a reliable negative result can be obtained. It may even be necessary to quarantine contacts of contacts. By using an approach to quarantine of “COVID-positive until proven COVID-negative” the containment of clusters is guaranteed.

Everyone quarantined should be quarantined in isolation. People suspected of being infected with COVID-19 should not be quarantined together lest one of them be positive, one of them be negative and the positive one infects the negative one.

Everyone who is quarantined should be paid compensation.

The key challenge here is testing everyone who develops a fever. This will require the mass-production (or mass-importation) of COVID-19 testing equipment. As of February 25^th China announced it was making 1.7 million nucleic acid based tests and 350,000 antibody tests per day as time goes by that number will only increase.

If not enough tests are available to test everyone who develops a fever for COVID-19, one option would be limiting tests to older adults with fever, as incidences of fevers generally decrease with age or to only test those who are also experiencing a shortness of breath along with a fever. Although only 18.6% of people with COVID-19 experience a shortness of breath, due to the fact that there are multiple individuals in each cluster, even these more restrictive criteria should be sufficient to identify new clusters of infection.

Beyond that, there is the man-hours which testing and contact tracing involves.

To the greatest extent possible, the testing of individuals with fevers should be performed by unskilled, rapidly trained volunteers rather than healhcare professionals (as healthcare professionals will have more important uses of their time)

Accuracy is not critical for the first sweep of testing everyone with a fever to identify new infection clusters, as there will be mulitiple COVID-19 cases in each cluster who develop fevers. Even if tests which hastily-trained volunteers conduct yield 80% false negatives, provided there are substantially more than 5 people in a previously undetected cluster, then the infection cluster as a whole will be detected. The most desirable characteristic of these first pass test kits is that they don’t yield false negatives.

Once a new infection cluster is identified, at that point, teams with higher skill levels can be recruited to perform contact tracing and to test and quarantine all of the contacts of anyone who tests positive for COVID-19. If the entire society meticulously practices social distancing, (not contacting other people outside of your immediate household with the exception of economically necessary activities), this process of contact tracing will be far simpler, quicker and more straightforward. Indeed, provided social distancing is observe by the whole of society, this process of contact tracing and quarantine may be successfully deployed to contain even quite a large outbreak. As the outbreak gets larger, it may become increasingly necessary to rely on self-isolation and community supervision of the premises of those self-isolating as opposed to a quarantine that is managed by healthcare workers or other direct employees of the state.

Perhaps, to encourage reporting, a cash prizes of $2500 could be offered to the first member of a new, previously undetected, infection cluster who tests positive for COVID-19.

The ECDC has told countries to take a rational approach and conserve testing, contact tracing PPE use and hospitalization for high-yield situations.

In the case of any scarce resource, it is important to use that resource efficiently. Nevertheless, the mass-production of tests and the mass conduction of tests is the highest priority for any containment effort.

Containment will fail unless new infection clusters are promptly, and rapidly, detected.

New infection clusters can only be detected with sufficient rapidity if massive amounts of tests are roled out.

If europe cannot mass-produce test, then it must mass import COVID-19 tests from a country that can.

This is the only way to contain this plague.

Infection Tight Borders

 

Eliminating, or vastly reducing, the COVID-19 spread within the community of a nation is little use if vast numbers of infected people constantly pour into that nation from locations where the disease is still rife.

Due to the negative effect on tourism and business, many nations cannot be trusted to be fully honest about the number of COVID-19 infections occurring within their borders. The most robust way to deal with it is to test a random sample of 1% of travellers from foreign destinations, as they enter the country’s ports and airports.

If 1 traveler from a foreign country tests positive for COVID-19 then test every traveler that enters from that country and force the travelers in question to pay for the test as a condition of entry.

If more than 0.1% of travelers test positive for COVID-19: close the border with the country in question with respect to all travel that isn’t essential to the nation’s interest.

The beauty of this approach is it directly tests the thing that matters: the number of infections that enter the country from a given destination. If the disease-exporting country can successfully ensure COVID-19 cases don’t get aboard its plane, then an open border can be maintained with it even if COVID-19 cases exist at a low level within its borders. This approach of direct measurement on entry is also robust against the use of conduit countries. For example, if country A has closed its borders with country B but not country C, and country C has not closed its border with country B then, if a significant number of infected travelers from country B fly to country C and then fly from country C to country A, then country A will rapidly detect a rise in infections from the random sample of tested travelers arriving from country C see and will rapidly demand that all travelers entering from country C must pay to test themselves for COVID-19 before entering country A.

Home Delivery And Efficient PPE Use

 

The key to reducing the spread of infection is to divide society into closed interacting groups where different groups minimize physical interaction with one another (ofcourse widespread digital communication between members of different groups is fine). Broadly speaking, we can divide the components of the necessary interactions in our lives into:

1. Social (Limited to a closed household during the pandemic)
2. Financial (The workplace)
3. Material (Where we spend the money we earn on goods we want – the market)

Most B2B businesses have stable relationships with a small number of suppliers. In this sense, so long as employees in any business always work with the same co-workers, then if an outbreak occurs, then so long as physical interations between suppliers and customers are limited, its spread will be limited to the workers in that business along with their respective households. This is why I mentioned, in the section “What Does Social Distancing Mean?”, that it’s very important for the containment effort that people who go to different places of work should not live in the same house.

This avoids a workplace-household-workplace-household-workplace-household chain of COVID-19 transmission.

However, at the end of every production chain is the final customer, and if the ultimate output is a mass prroduced good, then that good must also be mass-dispersed to the final customer.

It is crucially important that the mass dispersion of mass produced physical goods do not also mass-disperse the coronavirus as part of the delivery process.

Consider the two different ways of delivering goods to final customers

• Goods are delivered to shops and then a bunch of random customers mill around the various shops handling the merchandise, breathing the air in the enclosed space, coughing, etc.,

or

• A single delivery man delivers goods to 500 different customers every single week

In order to effectively prevent the spread of infection in the shop, ever single customer of that shop must equip themselves with PPE. However, in order to prevent the spread of infection during the process of directly delivering goods to people’s doors, only the delivery man must equip himself with PPE and if he drops off goods at doors of customers, without asking them to sign, then the entire delivery process is relatively safe – certainly far more safe than lots and lots of different shoppers all breathing the air in the same enclosed space of the shop.

Door-to-door delivery is a far safer way for customers to acquire the goods they need when compared to shopping. The practice of signing on delivery should be halted. Delivered goods should be dropped at the door, confirmation of receipt should sent by text instead.

Furthermore, scarce PPE resources should be focused on last mile delivery men.

Indeed, the two professions that require PPE more than any other are:

1. Healthcare professionals (including testing and contact tracing teams)
2. Last mile delivery men (wrt to both letters and parcels)

These are the best areas to apply PPE in order to limit the widespread dispersion of COVID-19.

People should cook their own food. Takeaway food that has recently been prepared can be a vector for viral transmission.

 

Dynamic Lockdown

 

Hopefully things won’t get bad enough to require an entire city to be completely locked down as it was in Wuhan, but the geometric logic of locking down large population centres is inescapeable : the circumference of a circle increases in proportion to the radius, whereas the area of a circle increases with the square of the radius. Threfore, 2 times as many police/military personnel can enforce a quarantine over 4 times as many residents, 3 times as many police/military can enforce a quarantine over 9 times as many residents, etc.,

What didn’t make sense in Wuhan was confining healthy individuals in the Locked Down area. Healthy individuals that would otherwise be capable of contributing to keeping the country going.

In a dynamic lockdown, which would occur in areas where the rate of infections crossed a certain threshold:

1. Every resident would be instructed to stay in doors, to immediately halt the rate of further transmission

2. Healthy (and later also fully recovered) residents could then apply online to emigrate from the locked down area.

3. The emigration process from locked down areas would be as follows:
   1. To qualify, applicants must not have had fever anytime in the past month
   2. To qualify, applicants must conform to lockdown orders, applicants seen leaving their house without a permit will be disqualified for emigration
   3. Applicants are delivered a COVID-19 self-test pack through the letter-box
   4. One by one, qualifying applicants are driven by volunteers to an emigration facility
   5. At the emigration facility, further tests are done, and once their lack of COVID-19 infection has been confirmed to a high level of certainty, they are free to leave the locked down area and receive some compensation for the inconvenience
4. In the event, that quarantine facilities or self-isolation isn’t effective in areas with lower levels of COVID-19 infections, quarantined individuals (who have either tested positive, or are in an incubation period) outside of the locked down area will be transported into the locked down area and allocated a house of someone who has emigrated as a result of testing negative for COVID-19

This would both allow uninfected residents of the locked down area to leave and become productive members of society during the crisis while also effectively turning the entire locked down area into a giant quarantine facility. With each house, effectively isolating the respective individuals in quarantine from each other (so that people who are not infected during quarantine won’t infect those who are).

Delivery men deliver essential goods to people’s door inside the locked down area. Residents are paid a lock down allowance. Rent and mortgage payments are suspended.

Controlled Infection Of Key Workers

 

As I mentioned before, “flattening the curve” infect the entire country at a “manageable pace for the hospitals to cope with” and thereby build herd immunity up across the whole country would take an impossibly long time. Approximately 40 years.

However, the NHS employs 1.7 million people, that is about 2.6% of the total U.K. popultion of 66.4 million.

This would imply, it may be possible to manageably infect all young NHS employees with no other underlying health conditions that would place them in the at risk group in a staggered manner over a timeframe of less that 1 year. And although young people without health conditions still do sometimes develop serious complications from COVID-19, the rate a which they do is much lower and even for those who do, provided they are given adequate medical attention, their likelihood of living through it is much higher.

Another issue is that exhaustion, makes those who are infected with COVID-19 far more likely to succumb. So if there was a proper policy of infecting young healthcare workers with COVID-19, telling them to chill out and take it easy, eat a nutritious diet, and get plenty of sleep before they even start to develop symptoms, they will be much more likely to fully recover without too many complications compared to a scenario where those same healthcare workers get infected in the middle of a crisis situation where they are stressed out and worked to the bone.

Although developing herd immunity, in the general population would take too long, there may well be a case for deliberately cultivating herd immunity in healthcare workers that are at low-risk of serious complications before things get to crisis levels, these immune healthcare workers could then be deployed strategically to protect older health professionals who have a higher risk of infection.

Finally, the manner of controlled infection should be conducted so as to minimise the evolution of the virus. Long chains where A infects B infects C infects D and so on, facilitate evolution (and the more COVID-19 strain evolve, the harder it will be to develop a vaccine for all of them). Conversely by preserving a sample of virus in longterm storage and then infecting all the non-at-risk health workers gradually, in a staggered way, from the same sample and then telling them to self-isolate and order what they need by delivery this mass-immunization process will minimally facilitate the evolution of the virus.

 

Empty Streets Mandate For High Crime Areas

 

 

Normal policing involves a lot of human interaction, gathering evidence, talking to people, finding out if they’ve done anything wrong. Perhaps even manhandling individuals who are trying to escape arrest.

Many of these business-as-usual activities run a high risk of infecting police officers along with any individuals the may interview, interrogate or arrest.

If we don’t want COVID-19 to spread through the police force like wildfire, and take a large chunk of the police force out of action in the process, the nature of policing will have to significantly change during the COVID-19 pandemic (at least in hard hit areas).

It is an inescapable fact, that, in order to enforce compliance from a distance, and keep the police force safe from infection during the pandemic, the police will need to make greater use of projectile weapons such as guns (even if they shoot tranquilizer darts). Arrests will generally take the form of police pointing projectile weapons at criminals and suspects and ordering them to get into the back of the van or else they will shoot.

Social distancing, if well-enforced, will tend to reduce serious crimes, as injuring or killing people requires close proximity. So other than crimes between members of the same household, an empty streets policy would make policing much more efficient.

It would also simplify reporting. Normally, when people see a group of individuals walking down the street, they have no idea whether that group is a criminal gang or a group of law-biding individuals engaging in some legitimate activity, it is only when that group assaults someone, or breaks into a house that bystanders will be able to identify that the law has been broken and can phone the police. At this stage however, it is unlikely that the officers of the law will arrive on time. Furthermore, they must get statements and testimony to the effect that the law has been broken

An empty streets policy, in badly affected areas, would simplify all this. The instant the residents of a community saw people walking down the street, they would instantly know they were violating the empty streets mandate. The residents could immediately call the police. The police, or military could then appear with guns and order the violators from a distance to get in the back of a van where they could be arrested and detained – at least for the duration of the pandemic. No witness interviews would be required, if they were walking the streets, they are violating the mandate.

Such a policy, if enforced rigorously in a particular area, would have the effect of drastically reducing burglaries and fights in that area.

Perhaps in some areas, where crime is low, it would not be necessary to enforce such a policy, but, if push comes to shove, it would be a simple solution to protect residents in high crime areas from attack while, at the same time, protecting the police and military by enabling them to protect the public while simultaneously reducing their own risk of infection.

Monetary Policy

 

Money is how we decide how to distribute the beneficial, yet scarce, resources which are available. Everyone needs some scarce resources, which is why most people are willing to spend a great deal of their lives working for money. To a first approximation, during normal times, all we need to do is ensure that transactions between customers an sellers are voluntary and ensure that sellers deliver their services to customers as promised, and then throw a few environmental, employee safety and minimum wage regulations on top and then broadly speaking, members of society should behave, roughly, in such a manner so as to optimally serve each other’s needs and wants.

During a deadly pandemic, much of this changes, as many commercial interactions that would otherwise be harmless or even beneficial, during normal times, may serve to spread the deadly contagion and, by so doing, can become potentially lethal. Yet not everyone who has trained for their entire lives to perform a particular job for a wage – which during a pandemic might tend to increase the spread of the virus – can rapidly switch to new ways of doing things that will both:

• Reduce the spread of the virus

• While at the same time earn a living from customers

While some people may be able to change the way they work to perform services for customers in new ways that reduce the risk of infection, others may have to cease working altogether. It is essential that the portion of society which ceases work, as a result of the pandemic, be given enough money to be able to continue to procure the means to live.

There are seven measures the government should take to ensure that no one feels financially obliged to continue performing an unnecessary economic activity that contributes to spreading COVID-19 throughout the population:

1. Quarantine Allowances
2. Quarantine Finance
3. Work Prohibition Allowance
4. Work Prohibition Finance
5. Cluster Identification Prizes
6. Rent Collection Suspension
7. Mortgage Payment Suspension
8. Suspension of Interest Payments

Quartantine allowances are made available unconditionally to anyone who is ill or who needs to be quarantined for a short while as people run tests to make sure they are COVID-19 negative.

Work prohibition allowances occur when someone’s job is either:

1. Economically unnecessary and greatly contributes to the spread of the disease
2. When two or more people who commute to seperate workplaces cohabit the same household, one must be prohibited from working in order to break the workplace – household – workplace – household – workplace chain of transmission, by default, all workers who are prohibited from working will immediately receive a workplace prohibition allowance. However, they may be required to retrain or apply for non-prohibited jobs, and demonstrate as much, depending on their skill sets

Quarantine finance and work prohibition finance arise from the fact that some people have become accustomed to a higher standard of living than others. And while people who are isolating themselves equally should receive equal pay, those who, for whatever reason, live lives with higher levels of fixed expenditure than others, should receive additional finance at low interest to avoid hardships and disruption do to high fixed living expenses. All extra finance must be repaid eventually, perhaps quarantine finance could be run in a similar manner to student loans where you don’t have to pay it back until your income exceeds a certain threshold.

Cluster identification prizes are there to encourage people with COVID-19 like symptoms to get tested. $2500 should be paid to anyone who tests positive as part of a new cluster that cannot be linked to existing clusters – provided they have observed reasonable social distancing precautions.

Rent collection and mortgage payments should be suspended. With mortgage payments suspended, most part-time landlords should be able to afford to halt the collection of rent. Banks will not have to pay interest out to savers or bondholders, so the mortage repayment moratorium will not cause them to collapse. The central bank can furthermore offer longterm 0% interest loans to private banks to ensure they have the cash on hand to pay out depositors.

With such measures, it should be possible for everyone to adhere to quarantines while continuing to procure the finances necessary to live.

 

Beating It Down During The Summer

 

COVID-19 initially escaped from China after mid Januiary as the flu season was starting to wind down. Probably, until mid-February cases in the majority of countries were in the triple digits. Yet, now in March, things are really starting to slip out of control, with many countries witnessing rapid exponential explosions in their respective case numbers.

There seems to be a fairly consistent trend of slower growth rates in countries by the equator and in the Southern Hemisphere. However – please note – although infection numbers in the Southern hemisphere and on the equator are growing more slowly than those in Northern climates, they are still growing!

What summer might do, if we are lucky, is slow the rate of the exponential growth in cases, to give countries where things really seem to be getting out of control (Italy, Spain, Germany, France, the U.S., possibly Canada, Switzerland, the U.K. and Norway – Iran may be too far gone already) just enough time to put the breaks on the growth rate if combined by a comprehensive slew of other highly aggressive containment measures. Please note, it will not be enough for countries with advanced outbreaks in the triple digits to merely stop infection numbers of COVID-19 from growing during the summer, IT WILL BE NECESSARY TO BEAT THE NUMBER OF COVID-19 INFECTIONS BACK DOWN INTO THE DOUBLE OR, AT MOST LOW TRIPLE DIGITS before next Autumn THIS IS CRITICAL!!!

With aggressive containment measures in place, along with preparedness and constant vigilance, it will probably be possible to keep whacking down and containing infection clusters as they arise during the winter flu season, so long as the initial number at the start of the season are in the low triple digits or less.

 

The Post-Outbreak Future

 

In his infamous “herd immunity” interview Sir Patrick Vallance told Sky News that if you lockdown infected areas in the country for 4 months straight you could successfully suppress the virus, but then argues against lockdowns based on the fact that all of the evidence from previous epidemics suggests that after suppressing the virus, if you then relax the restriction “it all comes back again.”

He’s probably right.

However, the last previous highly lethal epidemic, that was sufficiently deadly to justified a resource-intensive containment response, was over a century ago. And, technologically speaking, the world is very different today to what it was 100 years ago.

Our medical system today is much more responsive. Consider how effective tests for COVID-19 were developed weeks after the initial outbreak. It’s certainly true that if after suppressing the virus for 4 months through lockdowns, when we then relax those lockdowns, clusters of infection will once again spring up. However, the number of infection clusters will be much smaller – after lockdowns and suppression – than before and, on the otherhand, in the intermediate period during the 4 month lockdown, the rate of production for COVID-19 testing equipment will have ramped up and be much larger.

In addition to this, during those 4 months, it will also be possible to deliberately infect, and hopefully immunize, a number of NHS workers, who fit in the low risk group, with COVID-19, creating herd immunity, at least in healthcare settings, where immunized healthcare workers are strategically deployed in the required concentrations to ensure such herd immunity.

Furthermore, in 4 months time, stocks of PPE will also be larger.

So, yes, even after successfully suppressing the outbreak and relaxing the lockdown it will be necessary to continue to test everyone who develops a fever, promptly for COVID-19 infection and in the case of small localized outbreaks, alert the population in the area and encourage social distancing and the wearing of PPE, where convenient, ( but nothing as severe as the kind of lockdown prior to suppression ) while rapidly sending in a contact tracing team to identify all the contacts, to test and quarantine the entire infection cluster.

This state of high vigilance, of constantly testing those with a fever for COVID-19, will need to be maintained for many months, possibly many years, after the initial outbreak has been quenched. And while it will be possible to relax social distancing considerably once the outbreak is quenched, eveyone must remain prepared and ready to rapidly reinstate at least some of the social distancing measures in the event that an infection cluster is discovered in their local area (although for any one locality, this will be an occassional and comparatively short-live event – at least when compared with the initial lockdown). And random samples of travellers entering in from from foreign countries will also need to continuously be tested long after the main outbreak has been quenched. Teams of contact tracers will need to remain on standby and be ready to mobilise the instant a new infection cluster gets detected.

How long will this state of constant vigilance need to last?

The lockdown itself may well last for up to 4 months. With respect to the high alertness and readiness to instantly and rapidly respond to re-emerging infection clusters, it really depends on the schedule for vaccine development as well as the development of anti-viral drugs.

A vaccine is likely at least 18 months away, and even this is wishful thinking, as the schedule for developing a vaccine against an entirely new species of virus that is constantly evolving into new strains is uncertain. What does seem clearer is that there have been many promising results for treating this disease with anti-viral medication, and the like. Some doctors have tried treating pneumonia with vitamin-C, hydrocortisone and thiamine while clinical trials, that involve treating COVID-19 patients with remdesivir, are being conducted as we speak. Thai doctors have observed that a cocktail of HIV and flu anti-viral medication have produced improved outcomes for coronavirus patients in Bangkok. Australian researchers have also recently announced they have found a cure to COVID-19.

If either a vaccine can be found that reliably confers immunity to COVID-19, or a treatment with anti-viral drugs, which can affordable be mass-produced to reliably treat everyone with COVID-19 that eliminates the requirement of a respirator, or other expensive equipment, in the vast majority of cases then under those circumstances, it might be feasible to ease up on social distancing and allow the virus to let rip after a suffiiently large stockpile to treat everyone has been built up.

But, at least for the first year or two after the main outbreak is quenched, the post outbreak future will be a very different society to what we have today, and we may well remain on a state of high alert for several years going forward, even if relatively few people die and infection clusters can be successfully and rapidly suppressed as they arise.

The one upside in all of this is there is some evidence that the fear of COVID-19, in Japanese Society at least has brought a rapid end to the flu season. So the tentative possibility exists that all these efforts to contain the coronavirus may as a side effect, deliver a death blow to regular influenza.

 

Conclusion

 

If we take “containment” to mean halting the exponential spread of COVID-19 and reducing new infections to a residual linear trickle, then if we throw everything we have at this virus, as the suggested measures in this article lay out, this outbreak should be possible to contain even at the level of 100,000 to 1 million infections per country. Although, obviously, the larger and more well-distributed the outbreak, the more difficult, protracted, and expensive the containment effort will need to be.

This containment effort cannot succeed without deep determination and commitment on the part of every member of society. This time, we cannot just go about our daily lives and “leave it to the professionals” to sort this out. If we are to stand a chance of containing COVID-19, and avoiding a death toll comparable to that World War II, then everyone must do their bit. At this stage in the outbreak, quarantining and contact tracing can only work if meticulous social distancing is practiced by every member of society to the very limits that a functioning economy will allow. Only then will contact tracing be simple enough, and the growth rate of the epidemic slow enough, to enable disease control specialists to get ahead of it and push the R0 of the virus below 1 – even at this late stage.

And even after suppressing the main outbreak, we will need constant alertness, along with the active and rapid identification and suppression of infection clusters, as they emerge from time to time, for seveal years to come.

All this will be incredibly difficult to pull off and will require an incredible effort, but hundreds of millions of lives depend upon our success. The lives of a similar percentage of the world’s population which died during World War 2 (more in absolute terms) hang in the balance.

If World War 2 was worth throwing everything into, then so is COVID-19.

If we don’t care about 100’s of millions of people being killed, then why did we fight Hitler?

Today, the British government is afraid to instruct people to engage in extreme social distancing now for fear they won’t be able to sustain it for four months and will get fatigued, yet if, prior to Wold War 2, we operated on the assumption that our soldiers would get fatigued after 4 months of fighting, we would have surrendered rather than resisted.

If soldiers can fight wars for years on end to defend their countrymen, then is it really too much to ask people to stay indoors in comfortable suburban houses, with home entertainment systems and food delivered to their door, for months on end, in order to protect millions of innocent people from being slaughtered by this virus?

Because the virus is completely new, we do not know how long immunity against it lasts, we do not know how it will mutate, in the future, and as such, we do not even know if the projected mortality rate of 3-6% percent is a once off, or whether the virus – once is gets loose – will infect a substantial fraction of the world’s population and kill a few percent of the world’s population year after year after year. Herd immunity at this point is still speculation. We do not yet know if people develop immunity to COVID-19 and even if they do, the duration of their immunity, the strength of their immunity and the extent to which their immunity will be effective against subsequent stains of the virus that may evolve.

There is no guarantee that if this virus escapes, and becomes another seasonal illness, that it will become drastically milder than it currently is, or that the death toll that different strains of it inflicted upon us season after season, will be drastically lower than the current projected death toll.

We must not surrender! We must resist this virus!

We must throw everything we’ve got into containing it!

Containment or Bust!

John McCone