The Grand Experiment: California vs Kansas, South Dakota and Sweden
Across the world a grand experiment is taking place between countries and states which have employed aggressive social distancing measures versus those which have employed less restrictive ones. The more aggressive social distancing measures produce more economic costs, but will hopefully reduce infections, deaths and the time the economy needs to be partially shut down. Less aggressive social distancing efforts may reduce economic costs, at least in the short term, but may produce more infections over the longer term.
Three states in the U.S. exemplify these differing approaches: California, Kansas and South Dakota. The goal of social distancing is to “flatten the curve”; i.e. reduce the number of infections so that the infection dies out more quickly and with fewer deaths, and possibly less economic pain. Let’s see if it’s working.
By all rights, California should be a basket case right now. The most populous state in the nation, it’s the main entry point for people coming from China and they have been coming – in the tens of thousands over the past month or so. Yet California is doing well.
Gov. Newsom’s March 19th, stay-at-home order, which also closed educational services and non-essential services, basically shut the state down.
(Contrast that with the federal government’s more moderate March 16th recommendations to not gather in groups larger than ten and to avoid bars, restaurants, etc.)
The Institute for Health Metrics and Evalation (IHME) April 13th model projects that California hospitals will meet their peak resource use tomorrow, and that California is well-prepared. The model also projects a remarkably small and shortened curve: i.e. it appears that by acting quickly, big, heterogeneous, busy California has dramatically “flattened the curve” and will be able to open for business earlier than other states.
Kansas closed its schools before California (March 17th) but didn’t implement a stay-at-home order until March 30th, and never closed non-essential services.
The IHME model predicts that Kansas will reach its resource peak two weeks later than California (Apr. 29th) and has a significantly higher and longer coronavirus “curve” than California; i.e. it’s projected that the virus will be present and placing a significant strain on hospital resources much longer than in California.
South Dakota closed its schools even earlier than Kansas (on March 16th), but never implemented a stay-at-home order or closed non-essential services.
The IHME model projects that those decisions may cost the “Mount Rushmore” state. The projected curve of increased hospital needs will be more intense and be present longer than either California or Kansas – lasting well into June.
According to the IHME, Sweden hasn’t implemented any of the four major social distancing measures: it hasn’t produced a stay at home order, it hasn’t closed non-essential services,and it hasn’t closed schools or severely restricted travel.
Sweden has become a kind of icon for a less top-down approach to the virus which emphasizes individual responsibility.
The IHME, though, predicts that Swedish health system will soon get overwhelmed and stay that way for almost two months.
Time will tell if the models are correct. There will also surely be an accounting of economic costs vs lives saved.
The Midwest Advantage
Some Midwestern states have taken advantage of their geographical isolation from the coasts, and the time that has afforded them, to implement contact tracing and may not need to shut down their economies.
A robust testing and contact tracing scheme is the best of both worlds: infections are quickly identified and walled off while the economy mostly hums along. The failure of the U.S. and other countries to institute robust testing and contact tracing protocols is one reason so many nations have been hit so hard – both economically and medically.
As the infections drop, the U.S. will have another chance at instituting a rigorous and thorough testing and contact tracing regimen.
The Next Steps
To say restarting the economy is difficult during a pandemic is to understate matters.
The number of new, confirmed cases daily has leveled off in the low 30,000’s and begun to drop. The number of tests being done every day (135,000) has also leveled off, making it a bit more difficult to say that the rate of infections is increasing.
The problem is that even after all these infections and deaths, and even as social distancing tamps down on the virus, and even as the curve flattens and falls, the vast majority of the population will still remain at risk from the virus – giving it plenty of “ammo” to rise up again. The U.S., after all, has about 600,000 confirmed infections. If ten times that number are infected or have been infected, that still leaves 320 million potential victims.
Dramatic times call for dramatic actions. We got through the 2008 financial crisis only because the FED and the Dept. of Treasury threw out the rule book and embraced every opportunity – even those which went against their belief systems – to save the economy.
Bill Gates in 2015
Can the U.S. do it? Bill Gates doesn’t think so. Gates, who’s been warning about a pandemic for years, and who’s been funding the organization – the IHME – whose models many have been using, said he believes that the federal government is still focusing on the wrong thing.
Coronavirus in the U.S. he said, is “still completely mis-prioritized. The natural thing would be to do like South Korea did, and create a unified system — that we haven’t gotten any interest from the federal level.”
Any test results, Gates asserted, have to come quickly enough for someone to isolate themselves before infecting someone else.
Testing Woefully Inadequate For the Next Step?
In order to safely prevent that from happening, the U.S. has to be able to quickly identify the infected – particularly the asymptomatic people – whom many believe are inadvertently driving the infection. That will require enormous amounts of testing – far more than the U.S., even with its dramatic ramp-up in testing over the past month, has been able to achieve thus far.
We shouldn’t pat ourselves on the back too much regarding testing. Germany, a much smaller country, is able to produce almost as many tests a day (120,000 – 135,000) while many places in the U.S. are still missing the reagants, swabs, etc. needed to do testing.
Estimates suggest that from 750,000 to millions of tests a day may be needed for the U.S. to be confident that it can identify those who are ill, quarantine them, and reopen its economy. One researcher wants the U.S. to test 25-35 million people a day and to continue doing that for several months. In a phone call, Ron Davis said he thought hundreds of millions of tests would be needed over time.
Doing something like that would probably require the U.S. essentially going into war status, and having the federal government use all its powers to implement the testing – something the Trump administration has been leery of doing.
An international team of researchers, however, has recently formulated a genetic test using barcodes which they say could easily be mass produced and provide millions of tests per day. Fifteen years ago, Ron Davis tried to get a grant from the CDC to produce a $1/test kit that could have been used for this very situation. (More on that later).
Dramatic Undercount of COVID-19 Deaths Expected
The 20,000 or so people who have died in the U.S. from COVID-19 is almost surely an undercount – a significant undercount. It has to be. Until recently, COVID-19 testing has been so pitiful that it wasn’t possible to test many people who died and their deaths were listed as heart attacks or pneumonia or other illnesses. All you have to do is track overall death rates to understand that our COVID-19 death rate is likely way off.
Cardiac arrest calls resulting in a death in a home jumped fivefold in New York City in the last half of March. A New Orleans doctor, Geraline Menard, reported: “When I was working before we had testing, we had a ton of patients with pneumonia. I remember thinking it was weird.”
This week, the CDC reported that the percentage of death attributed to flu and pneumonia is 10% – above the epidemic rate of 7.0%. The CDC stated: “The increase is due to an increase in pneumonia deaths rather than influenza deaths and likely reflects COVID-19 activity.”
Social Distancing For Two Years?
“Under current critical care capacities, however, the overall duration of the SARS-CoV-2 epidemic could last into 2022, requiring social distancing measures to be in place between 25% (for wintertime R0 = 2 and seasonality; fig. S11A) and 75% (for wintertime R0 = 2.6 and no seasonality; fig. S9C) of that time.” Kissler et al. 2020
A Harvard study published in Science that modeled the coronavirus infection over five years smashed any ideas that the SARS CoV-2 coronavirus will be a “one-and-done” thing. The models predicted that unless we want to see hospitals overwhelmed by virus victims, some form of social distancing will likely be necessary, at least on and off, for a couple of years.
Vaccines and herd immunity are what we count on to stop contagious viruses but we don’t know whether either will be effective. The problem with a vaccine is that coronaviruses, like all viruses, mutate. Mutation is only a problem if it occurs in the parts of the virus (its antigens) the immune system uses to recognize it and respond to it. The measles virus mutates so little in that part of the virus that a vaccine developed in the 1950’s is as effective today as it was then.
Coronaviruses, though, are cold viruses. Researchers have found 11 places it’s mutating – one of which allows the virus to attach to lung tissue. Thus far, little change has been seen in that part of the virus, but that could change as the virus starts to tangle with the immune systems of those who have become immune to it. Once that kind of evolutionary pressure comes to bear, the virus could start altering that area, rendering the vaccine less effective or ineffective.
Herd immunity, on the other hand, will help – but studies suggest that some recovered patients are not mounting a strong antibody response; i.e. they could quickly be re-infected again – and so will not contribute strongly to herd immunity.
Herd immunity is also likely not a great long-term option for SARS-CoV-2 because, if it’s like other coronaviruses, immunity will be short-lived – leaving those who recovered from it susceptible again a year or two later. (They tend to have less severe infections, though.) That suggests surges of the virus could happen every couple of years.
On the plus side, it’s possible, but not known, that people exposed to other coronaviruses via the common cold may have some immunity to SARS-CoV-2. If that’s true, SARS-CoV-2 infections could dramatically fade, and then once that immunity lapses, surge again in a couple of years.
While it’s not clear how effective a vaccine will be, a vaccine will certainly help. Developing treatments to blunt the severity of the infection will be crucial. Building out more intensive care units may be needed. It sounds like regular testing may be in our future for some time to come as well.
Clearly we’re in a great battle and the scientific community, at least, is rising to the challenge – creating collaborations and devoting resources that have never been brought to bear on a pathogen before. New tracking tools are being developed. Hundreds of clinical trials are underway. Automatic intelligence is being brought to bear. The amount of sophisticated technology being brought to bear on this virus is incredible.
If we can just get along and work together, maybe we can beat this thing more quickly than we think. Speaking of that…
WHO Did It?
The race is on to understand how the best prepared country in the world for a pandemic (remember that?) ended up leading the world in confirmed infections (now over 630,000) and deaths (26,213). Unfortunately, it looks like innocent lives are going to get ground up in the battle to lay blame.
Putting forth the argument that it was ‘them”: it was the World Health Organization (WHO) that essentially crippled the U.S.’s response, and so the Trump administration cut off funding to the biggest international health organization for 60-90 days. President Trump accused the WHO of “severely mismanaging and covering up” the coronavirus outbreak and said:
“Had the WHO done its job to get medical experts into China to objectively assess the situation on the ground and to call out China’s lack of transparency, the outbreak could have been contained at its source with very little death.”
There’s little doubt that the WHO could have acted more quickly, but the organization’s unique constraints should be noted. In order retain access to countries, the WHO rarely directly criticizes sometimes touchy government officials. During the Ebola virus epidemic, the WHO was similarly critiqued for not declaring a state of emergency earlier. It apparently held off doing that in order to keep access to the countries.
The funding stop – the U.S. funds a third of the WHO’s activities – won’t hurt the U.S. in the short run but it’s hard to believe that it won’t hurt many of the most needy at the time they will most need it. The developed world is getting hit harder right now because it’s more connected, but given the many densely packed cities with poor resources in the developing world, the toll there will likely be magnitudes greater. The International Crisis Group has warned of dire health and economic impacts that may de-stabilize nations, providing the opportunity for terrorist groups to flourish.
Besides its work on malaria, tuberculosis, polio, genital mutilation, etc., the WHO’s country-level teams are tasked with developing COVID‑19 Country Preparedness and Response Plans (CPRP) across the developing world. These plans identify gaps in each country’s preparedness and suggest ways to fill them. The plans – and the ability to implement them – will clearly be critical for many countries. Ironically, the Trump administration’s Pandemic Plan called for increasing funding for the WHO.
Since the outbreak began, the WHO has produced and sent millions of test kits to 126 countries – and was at one time offering them to the U.S. It has also shipped protective equipment to health workers in 133 countries. Bill Gates, who knows international organizations and global health like few others, warned:
“Halting funding for the World Health Organization during a world health crisis is as dangerous as it sounds. Their work is slowing the spread of COVID-19 and if that work is stopped no other organization can replace them. The world needs @WHO now more than ever.”
A Timeline of WHO and U.S. Events
January 9th – WHO warning that a new coronavirus had been found in China alerted health departments around the world to start tracking it.
- WHO’s attempt to get a team into China is rebuffed.
- The National Security Council knows the virus has probably escaped China, and warns President Trump not to trust China’s assessments. On January 24th, President Trump tweeted:
“China has been working very hard to contain the Coronavirus. The United States greatly appreciates their efforts and transparency. It will all work out well. In particular, on behalf of the American People, I want to thank President Xi!”
Jan 27th – Feb. 27 the Technical Situation Report from the WHO stated that it did not recommend travel restrictions.
January 30th – WHO calls the coronavirus a “public health emergency of international concern”, thus triggering the development of country-level plans and directives. It warns:
“The whole world needs to be on alert now. The whole world needs to take action and be ready for any cases that come from the epicenter or other epicenter that becomes established.”
February 11th – WHO Director-General Tedros Adhanom Ghebreyesus, reportedly frustrated at the paltry responses from many countries, states:
“To be honest, a virus is more powerful in creating political, economic and social upheaval than any terrorist attack. A virus can have more powerful consequences than any terrorist action, and that’s true. If the world doesn’t want to wake up and consider this enemy virus as Public Enemy Number 1, I don’t think we will learn our lessons.”
Mid-February – After reviewing the “Crimson Contagion” model in mid-February, the administration’s coronavirus task force determines that “aggressive social distancing” will be needed.
February 24th – President Trump tweets:
“When you have 15 people, and the 15 within a couple of days is going to be down to close to zero, that’s a pretty good job we’ve done.” “CDC & World Health have been working hard and very smart.”
March 13th – The WHO again states that it doesn’t believe that travel restrictions are effective stating “Countries may gain time in the short-term as they limit travel to fight the new coronavirus pandemic, but the World Health Organization thinks overall that “it doesn’t help to restrict movement”. The organization asserts that the key to stopping the spread of the virus is not stopping travel, but vigorous “testing, testing, testing” and contact tracing .”
March 16th – the Trump administration issues recommendations that Americans employ moderate social distancing measures (including not meeting in groups greater than 10 people, avoiding drinking at bars, going to restaurants). The next day, President Trump said he: “felt it was a pandemic long before it was called a pandemic.”
April 7th – President Trump stated the WHO “could have called it months earlier.” – well before before the first cases in China had been reported – and suggests “They probably did know” about the outbreak.
April 14th – President Trump suspends WHO funding as confirmed cases in the U.S. reach over 600,000.
Coronavirus Central – Resources From Health Rising
- Tracking – check out the multiplicity of ways the virus is being tracked: its spread, its infectious rate, the deaths it’s causing, efforts to model its effects.
- Advice From ME/CFS/FM Doctors and Researchers – ME/CFS/FM doctors and researchers give advice.
- Staying Safe – how to stay safe: including hand washing, nasal irrigation, disinfecting, making a mask, plus – is the virus being aerosolized? How long is the virus alive on different surfaces, and does the amount of virus present matter?
- Treatments – Check out the astonishing number of COVID-19 treatment trials underway.
- Apps – be part of the solution; use apps that help us understand the spread of the virus; plus, use apps that can warn you if you’ve been in contact with someone who is infected.
The Coronavirus Series From Health Rising
- Coronavirus #I: Dark Sun: Reflections on the Coronavirus as it Heads For Town
- Coronavirus #2: Scary Models, 8 Reasons People with ME/CFS and Fibromyalgia Should Be Careful, How to Stop an Epidemic, Why You Should Trust No One and More
- Coronavirus #3: Is the U.S. Becoming Italy? A Singapore Success Story, More Scary Models, Remdesivir to the Rescue?
- Coronavirus #4: Lipkin Gets Hit, Testing Woes, Could the Models Be Wrong, Ikea Ventilators?, and What’s Next (???)
- Coronavirus #5: Lipkin, Bateman and Klimas Talk Plus Treatment Updates
- Coronavirus #6: Will COVID-19 Leave An Explosion of ME/CFS Cases in its Wake?
- Coronavirus #7: Records Broken, An ICU Doctor Talks, The Peak is Coming, Hot Spots, Is it in the Air? Dr. Hyams on COVID-19
- Coronavirus #8: The Grand Experiment, Starting Up? Social Distancing – For 2 Years? WHO Did It?
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