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Our war against the coronavirus involves three battles. We lost the first. We’re winning the second. The third is yet to come.
The first battle was for containment. We won similar battles with recent scary viruses, like SARS, MERS and Ebola. They started overseas and largely remained there. COVID-19 was harder to stop, to be sure, but our government’s slow response, including the failures in creating tests, certainly didn’t help.
The second battle was to flatten the curve. And at this, we’ve done rather brilliantly. People have stayed home. The contagion rate is approaching one or is actually below it in most communities around the nation. People have sacrificed much, but we are winning it.
The third battle is for recovery. If we do not win this one, we lose the war. Unfortunately, the nation looks poised to enter the battlefield too early, before we are ready for it. That could result in a second wave of infections, potentially even larger than the first.
Here are four strategies we can choose from for the recovery battle, from fewest deaths to most deaths.
1. Stay closed until the virus is eliminated or we have a vaccine.
2. Test, trace, and contain until elimination or vaccine.
3. Herd immunity for most, quarantine the vulnerable.
4. Open the doors, go back to normal.
Let’s talk about each.
Option 1: Stay closed
This was perhaps best represented by a statement made by Ghana President Nana Akufo-Addo in March: “We know how to bring the economy back to life. What we do not know is how to bring people back to life.”
This option results in the fewest deaths. And yet, we’ve seen why this path is pretty unsustainable in the long run. In the United States, 22 million workers have filed for unemployment over the past four weeks, including more than 100,000 Utahns. Somewhere between a quarter and half of Americans live paycheck to paycheck. A $1,200 per person stimulus helps, but for only a short time.
Furthermore, it turns out that not everyone will obey shutdown orders. While the numbers are still small — 60% of people are more concerned about the virus than the economy — the minority is loud. These critics have shown in Salt Lake City and elsewhere that they will even gather in large groups to demonstrate their displeasure.
People who refuse to socially distance or follow health orders can get the virus in many ways — at these illegal gatherings, in jail if you arrest them, and elsewhere if you don’t.
After three controversial weeks, Ghana ended its strict lockdown Monday in favor of our second option, a containment strategy.
Option 2: Test, trace, contain
This is the option many people prefer because if well-executed, it minimizes both deaths and economic hardship. It is the path Utah and much of the nation is on.
You allow most people to go to work, but test a huge percentage of them regularly for the virus. If a positive case is detected, you work diligently to test anyone they’ve contacted. People with the virus are quarantined until they’re healthy. Everyone else goes about semi-normal lives.
The number of tests you need to effectively implement a test-and-contain strategy is a matter of significant debate: Some say it’s about 500,000 per day in the U.S, some say it’s 20 million per day. You also need many more workers to trace who these infected people have come into contact with, about 100,000 more in the U.S., according to a Johns Hopkins report.
Here’s the thing: I don’t think it’s going to be enough to eliminate the disease.
If it were going to work, it would work best right here in Utah. Perhaps, no state is better positioned to pull this off. We’re the only state in the top 10 in testing and in the bottom 10 in deaths. Our positive test rate remains very steady at about 5%, far lower than the rest of the country. Community spread was at 15% last week. All of the above is very impressive.
According to a map tweeted by Lt. Gov. Spencer Cox, Utah has more than 9,000 tests available per day for Utah’s population, a higher rate than just about any other state. I’ll do the math for you: If the whole U.S. population had access to tests at that rate, it’d be about 1 million per day. Maybe Utah’s current amount is good enough, maybe not. Utah is also working on getting the 1,200 contact tracers needed, with about 300 people already trained and 600 others available. It’s a terrific start.
And yet, Utah is still a member of a nation of 50 states. All of the other states are behind by a factor of two or three, sometimes more. Worse, some are choosing to do reckless things.
Georgia Gov. Brian Kemp, for example, is opening gyms, barbershops, tattoo parlors and bowling alleys on Friday. Yes, this week! Officials have counted more than 19,000 cases of COVID-19 so far. Remember how 60 choir singers in Washington, all asymptomatic, went to practice one day and 45 got the disease, with two dying? Opening gyms and bowling alleys with the virus still around seems insane.
It might be easy to say that Georgia is on the other side of the country and what happens there has little impact here. But there’s always the Delta connection. It’s hard not to think about the number of flight personnel who spend part of their week in both Atlanta and Salt Lake City.
Even closer to home, there are worries. The Las Vegas mayor called her city’s shutdown “total insanity,” but it’s hard to imagine a place more conducive to spreading a virus than a casino. Tens of thousands of Utahns go to Vegas annually.
We’re trying to get information from those coming and going, but that has run into problems. More than 10,000 forms were filled out in the first three days of Utah’s border survey (it’s unclear whether that number includes surveys from those arriving by air). But the survey was essentially optional, and truckers were specifically excluded. The surveys were sent by automated texts that didn’t work right, and the state abandoned that effort. Now highway signs ask people to fill them out.
On average, over 50,000 vehicles enter Utah’s borders by road each day, and while I’m sure traffic is down and many drivers cross the border multiple times, we’re missing a substantial percentage of entrants.
Without significant federal intervention, Utah’s success at stopping the virus will be at least partially determined by the actions of other states, all of which are doing worse than we are.
Beyond the logistical problems, it seems like this virus may be impossible to stop with this strategy, anyway. According to one study released April 15, the coronavirus load in the throats of carriers is highest at or right before the onset of symptoms, leading to a pre-symptomatic transfer rate of 44%.
Another recent study found that contact tracing and isolation in this contagious of a virus only worked if the pre-symptomatic transfer rate was less than 1%, if there were 40 or more initial cases.
This goes without saying, but a transfer rate of 44% is greater than 1%. Many of the communities that will open up will do so with significantly more than 40 cases to track. This virus is too contagious, and we’re opening up too early.
I think the test, trace, and contain strategy is a valiant one that should slow the growth of spread, especially locally. It could allow our hospitals to avoid being overrun. We can use it to buy some time. But based on the evidence, I just don’t think we’re going to get the effective contagion rate below one if the economy opens soon.
Option 3: Herd immunity
If the effective contagion rate isn’t less than one, that means the virus will grow at either a constant or exponential rate. Some large percentage of the population will eventually get the disease until a vaccine is created.
If a vaccine doesn’t arrive quickly, you may have to settle for herd immunity, where the virus hits a majority of the population until it can’t find any more susceptible hosts and eventually dies out.
Some countries, like Sweden, have actually preferred this method from the beginning, because it does allow you to have more of the economy open if you have a shortage of tests. The thinking goes, if test, trace, and contain isn’t going to work, you might as well reduce the harmful secondary effects of the virus.
The downside is: Most of your country gets the coronavirus. Many of them get sick. Some of them die. Even if we go with our extremely conservative estimates in an article last week, something like 200,000 to 1 million people die in the U.S. and perhaps 3,000 to 10,000 deaths occur in Utah if a majority of the population gets the disease. We are very, very far away from achieving herd immunity.
Now wait, you say. What if we quarantine the vulnerable? Tell those over 65 or with preexisting conditions to stay home until we have access to a vaccine or near-foolproof treatment? It seems like a really good idea!
The problem is that it’s essentially impossible to quarantine the elderly. It might be easiest in nursing homes, where dozens of elderly can be cared for in one spot with minimal outside entry. That’s been essentially the plan in the majority of nursing homes in the U.S... and more than 7,300 people have died so far in those. Half of Utah’s deaths have come in these sorts of facilities.
But 93.5% of Americans over 65 do not live at nursing homes; they live in normal residences — that’s about 45 million people. And those people often either live with and depend on younger family members (remember, who are probably going to get the disease in this strategy) or participate in the local economy themselves. If a large percentage of the population has the virus at any time, they’re going to be in big trouble.
We can be careful with those most at risk, but they’re still going to be in significant danger if society is operating near normal.
Option 4: Open the doors
This option means hospitals get overrun, impossible choices are made about whom to save and whom to let die, many people die at home and from diseases that shouldn’t kill them, and millions of Americans and tens of thousands of Utahns lose their lives. It is what happened in Italy, what is happening in New York City, and there’s no reason it couldn’t happen here.
It is a terrible option. Nevertheless, it is what some are protesting for.
The truth is, none of the four options is great. No. 1 is infeasible for the long term. No. 2 is unlikely to work. No. 3 is deadly. No. 4 more so. That this is what we have to choose from reveals just how unprepared we are for this stage of the war; it also reveals some of the deepest cracks in our society.
It shows just how reliant we’re going to be on our scientific community to get us out of this mess. The end of this predicament isn’t going to be due to epidemiological wizardry, but through the development of effective treatments or a vaccine. We should support those efforts — and those of front-line fighters like doctors and nurses — however possible.
Until then, we can manage it to the best of our ability, and save many lives by doing so. I’m impressed with Utah’s efforts, and think we’re well poised to perform better than nearly every U.S. state. But the odds that we will eliminate the disease soon are small.
I wish I had better news. I really do. But, unfortunately, I have to tell you: In Utah and elsewhere, a second wave of the coronavirus is coming.