Intro
We are now several months into the Corona Virus pandemic, a point where fingers are pointing every which way, but there seems to be a light at the end of the tunnel. That it may be on oncoming train doesn't seem to be considered by those in power who lack a plan on how to deal with getting us back to normal, other than to say, it will all be good, everything will be back to normal. Do they have a plan? If so, it's not immediately apparent. One person in the know suggested that assorted plans were being considered; problem is that they all have appalling outcomes.
I listen regularly to a Vox podcast called "The Weeds" that discusses assorted items related to culture and the most recent was devoted to plans developed by several think tanks, the American Enterprise Institute, a conservative group; The American Progress Institute, a more liberal learning organization; and analysis of Paul Romer, Nobel prize winning economist and chief economist for the World Bank. (How Does It End?)
I decided to read the papers themselves and try to summarize what I found to be the salient points. I suspect, however, that given the structure of our republic and the fetish of individuality and independence that plague us, few of the recommendations will be even talked about, let alone accepted.
National coronavirus response: A road map to reopening AEI
Scott Gottlieb, MD served as the 23rd commissioner of the Food and Drug Administration (FDA) from 2017 until April 2019. He is presently a resident fellow at the conservative think tank the American Enterprise Institute (AEI). He's also on the board of Pfizer. He was best known for his vigorous attack on the opioid epidemic. He was widely praised and his resignation after only two years in the Trump administration was considered to have left a big hole. [https://www.vox.com/policy-and-politics/2019/3/5/18252139/scott-gottlieb-resigns-fda-opioid-epidemic] Just two months before he has adamantly insisted he was not leaving. He had come under fire from anti-tobacco groups for his stance on vaping and Americans for Tax Reform had argued his policies were inconsistent with the Trump administration's policies. Draw your own conclusions.
In order to move away from social distancing Gottlieb lists three requirements:
-Better data to identify the rate of exposure and immunity. That will require extensive testing.
-Improvements in public health infrastructure at the state and local level and to make sure we have adequate medical supplies
-Development of therapeutic and preventive treatments.
There are the obvious comments about harnessing technology and expanding investments in pharmaceuticals (he does work for Pfizer, after all, but it's logical -- whether those government supported efforts should become profit centers is another matter.)
They divide their plan into phases.
Lock-down is required of all but essential jobs although they make no attempt to define what is essential, a category that reportedly has been widely abused. That's the phase we are in early April. To reduce the number of infections testing of everyone with symptoms and their close contacts will be necessary. Provide support for the current health system. Only then can we move on to Phase II.
Phase II is state-by-state reopening but physical distancing and limitations on group gatherings needs to continue. Older adults will especially need to limit their community time. Deep cleaning of physical spaces. Those ill still need to self-quarantine. They make no effort to define the criteria as to just when a state or county can move to this phase other than to have multiple places where "confirmed cases cannot be traced back to other known cases", i.e. there is no evidence of community spread. My worry will be that the standards will be too loose to be effective. A return to physical distancing would be required if counts begin to double every three or five days or the health system begins to be overwhelmed (seems a bit late in my view.) Note that both Phases 1 and 2 require an enormous amount of testing. One estimate in another report said 7% of the population each day. That means about 24 million tests per day. Their report says that at least 750,000 tests per week would be adequate IF paired with contact tracing. The report also defines what a lockdown should consist of. It's pretty close to what we have here in Illinois. Ensuring an adequate health system capability they define as doubling current capacity to 5-7 ICU beds per 10,000 adults ,and having 5-7 ventilators per 10,000 adults at a minimum.
Physical distancing restrictions can be lifted only when tools are available to mitigate the risk including surveillance (undefined) and therapeutics or an effective vaccine is available. Gottlieb has been quoted as noting that we have never been able to create a vaccine against any coronavirus so assuming we can it may take as long as two years.
Rebuild readiness for the next pandemic
The report details an extensive new system for contact tracing and quarantine enforced by GPS tracking on cell phone apps. Masks should be worn by the public as recommended by WHO but PPE equipment needs to be reserved for health care providers.
A National and State Plan To End the Coronavirus Crisis by Zeke Emmanuel
The piece from the Center for American Progress looks to South Korea as a model for the way to approach the virus, emphasizing the importance of staying at home so much as to recommend a national policy of stay-at-home for 45 days beginning April 5th. Their point is that you can't have economic health without public health. Studies of the 1918 flu showed that cities who intervened earlier and were more aggressive had faster economic growth after the pandemic.
Testing also plays a key role in their plan requiring a test of everyone with a fever and every member of their household has access to a test along with instantaneous contact tracing and isolation of those who had come into contact with positive individuals. They would also place restrictions on mass transit and restrict public gatherings. They emphasize the importance of a national plan for social distancing; individual states should not be allowed to go their own way. The risk to other states is too great. They cite a Unacast study from GPS data showing only a 40-55 percent reduction in average movements of people. (Nowhere do they suggest how such a policy might be enforced; indeed, that's a flaw in all the plans mentioned in this piece.) As in Italy, the U.S. reacted too slowly initially ignoring areas that appeared to no have many cases mistakenly believing they had no exposure. It's imperative to break community transmission which can only be done with vigorous enforcement of social distancing.
The plan suggests that testing is key and needs to be ramped up to about 2.25 million tests during that 45 day window. We are woefully behind South Korea in the level of testing. That needs to be coupled with serological tests that are relatively inexpensive and provide rapid information on the spread of an epidemic to authorities by measuring antibodies present in an individual's system. A worrisome factor is whether individuals can be reinfected. "In theory, serological tests could also prove individuals’ immunity, clearing people to go back to work. The science of whether COVID-19 infection confers full or partial immunity, and for how long, is still unknown. The level of antibodies necessary to prove immunity is also unknown. A number of patients in China and Japan recovered from COVID-19 but were reinfected and became sick again." Current tests cannot always differentiate between normal corona-viruses and COVID-19 but there are hopes to make the test more sensitive to the differences.
This report also promotes the use of instantaneous contact tracing and isolation. Unfortunately as many as half of the transmission of COVOD-19 occur from asymptomatic individuals which makes manual contact tracing very difficult. Technological means using apps and GPS could help break the transmission but would require an enormous sacrifice of privacy and government intrusion unless anonymity could be assured. In my mind that's doubtful. Assurances that the data would be deleted after 45 days and held only by a non-governmental non-profit agency might help to allay those fears.
One of the more controversial proposals in the plan would require virtually shutting down travel On an average day before the virus 34 million people used public transport and 2.5 million people flew. Those mechanisms are virtually incubation tubes for the virus. They suggest special protective equipment for bus operators, TSA agents, required use of contact tracing apps by passengers, physical distancing in airports, (that will be fun in 3-across seating on an airplane) and routine sanitizing. All of this will, of course, require a great deal of funding. No mention is made of just where that is to come from.
The report emphasizes that N95 masks need to be reserved for health care workers but that homemade masks do provide a measure of protection and therefore should be used.
Mortality rates and mutation
Iris Fung, a friend of a cousin of mine, and clearly either a biology or chemistry major, wrote about the frequency of mutation rates of RNA viruses leading me to an article with this paragraph:
RNA viruses have high mutation rates—up to a million times higher than their hosts—and these high rates are correlated with enhanced virulence and evolvability, traits considered beneficial for viruses. However, their mutation rates are almost disastrously high, and a small increase in mutation rate can cause RNA viruses to go locally extinct. Researchers often assume that natural selection has optimized the mutation rate of RNA viruses, but new data shows that, in poliovirus, selection for faster replication is stronger and faster polymerases make more mistakes. The fabled mutation rates of RNA viruses appear to be partially a consequence of selection on another trait, not because such a high mutation rate is optimal in and of itself.
Whether this high mutation rate would make development of a vaccine much harder, I can't say.
https://journals.plos.org/plosbiology/article?id=10.1371/journal.pbio.3000003
Simulating Covid 19 by Paul Romer
Paul Romer was a joint recipient of the Nobel Prize in Economics and formerly Chief Economics of the World Bank. He has prepared some really interesting models that show the effects of testing on the course of an epidemic. The second paper modeling the difference between isolating at random or isolating based on test results is particularly enlightening. The graphic representation is often clearer than a written one.
https://paulromer.net/covid-sim-part1/
https://paulromer.net/covid-sim-part2/
https://paulromer.net/covid-sim-part3/
Summary
I have added links to all three reports and urge you to read them in their entirety. My summary is merely cursory and each deserves a more thorough reading.
Based on my reading of these reports, it's clear that we were, and remain, woefully unprepared for any resurgence of corona virus or any other pandemic. To reach that stage will require a massive shift in the allocation of resources as well as a huge cultural shift away from a focus on independence to a realization of how inter-dependent we truly are. Travel and sports industries may have to change the way they do business to avoid huge gatherings of people and that would probably include political events, possibly even in the way we vote. Telecommuting and work might have to become the norm rather than the exception and that may change the face of education as well as work.
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