Tuesday, April 21, 2020

COVID: Brass Tacks

Without a timely vaccine*, prophylactic, antiviral or other inexpensive therapeutic, COVID-19 may constitute as longstanding and impactful an event as WWI, possibly even the First Industrial Revolution, and certainly more significant than the Spanish flu.  Total deaths may not match past events but COVID-19 is a harbinger of things to come that will leave a profound mark on our bodies and psyche.

Endgames: Herd Immunity, A Vaccine, and More

Facts are stubborn things; and whatever may be our wishes, our inclinations, or the dictates of our passion, they cannot alter the state of facts and evidence.
        John Quincy Adams

According to Ed Yong of The Atlantic, we have three endgame scenarios.  Under the control scenario, number 1, which he describes as vanishingly small in likelihood, "every nation manages to simultaneously bring the illness to heel" similar to SARS in 2003.  Under the herd immunity scenario, number 2, the illness runs out of gas but "at a terrible cost" - 
both in terms of deaths and social and economics costs.  Under the vaccine scenario, number 3, we play a "game of whack-a-mole...stamping out outbreaks here and there until a vaccine can be produced".  I include antiviral solutions - such as remdesivir, favipiravir and baloxavir - in scenario three.

You can add three intermediate scenarios: monoclonal antibody therapy, convalescent plasma therapy, and testing for antibodies.  The first is in development.  The second is expensive.  According to Stacey McKenna of Scientific American and more reading, the third remains uncertain as questions persist around individual immunity and antibodies.  Let's assume testing is our intermediate scenario. 

According to Alex Putterman in the Hartford Courant, any "return to semi-normalcy will also require extensive diagnostic testing, contact tracing and isolation of infected people".  He also notes that, according to CNN, over 90 companies have told the FDA they are selling antibody tests with vary efficacy.  Germany on the other hand seems to lead the way on testing.  Regarding contact tracing, according to Donald McNeil, Jr. of the NY Times, the US may have to train up from about 2K to 300K tracers.  The number of asymptomatic carriers will complicate this effort as well. 

I want to be positive.  But, it seems to me, we are on varying levels of lockdown until we have a vaccine or other solution.  Herd immunity is not a likely solution without a vaccine - especially given the conditions of transmissibility and fatality here** as well as the potential long time length for incubation, infection, and recovery.  Remaining uncertainties around reinfection could help or hinder the argument for the immunity scenario listed above.  

You could argue that we can 'harden' ourselves and try immunity scenario but, as I said, we face a major headwind.***  Sweden is experimenting with this approach in a sense - not without even some limited success although their nation is not a dense one, which doesn't help most major nations such as the US. 

I suspect we are in for 2 or 3 years of undulating lockdowns - especially if no vaccine is found in the non-trivial short-tun such as 5 years or so.  I also suspect that over time we will choose a hybrid between scenario 2 and 3 and let people die - assuming reinfection questions fall in our favor.  I am not ignoring that without economic activity, a portion of our society and other societies will die.  If it’s not obvious, I believe more in scenario 3.

The President's New Clothing

I’m going to have to make a decision, and I only hope to God that it’s the right decision...But I would say without question it’s the biggest decision I’ve ever had to make.
        Trump, in April 2020, regarding reopening the country

The epidemiological model often cited by the White House, which was produced by the University of Washington’s Institute for Health Metrics and Evaluation, originally predicted 100,000 to 240,000 deaths by midsummer.  Now that figure is 60,000.  While this is encouraging news, it masks some significant concerns.  The institute’s projection runs through Aug. 4, describing only the first wave of this epidemic.  Without a vaccine, the virus is expected to circulate for years, and the death tally will rise over time.
        Donald McNeil, Jr., NY Times, April 18, 2020

Ms. Merkel has done what Mr. Trump has not. She has been clear and honest about the risks with voters and swift in her response. She has rallied all 16 state governors behind her. A trained physicist, she has followed scientific advice and learned from best practice elsewhere.
        Katrin Bennhold, NY Times, April 23, 2020

Writing about Trump is always demoralizing and unproductive.  The people who need to examine his character, leadership, and policies can't.  And everyone else already sees the problem.  Nevertheless...  

Perhaps as never before, Trump has more than ever before illustrated his singular weakness - one that is quite surprising: indecision.  Indecisiveness is not generally the weakness of conservative leaders.  His bombastic tendencies only highlights his overall rising failures.  He has made many notable mistakes here that his recent predecessors - Republican or Democrat - probably would not have.  

One, Trump dissolved the National Security Council directorate on pandemics two years ago.   Two, he ignored the 69-page Obama pandemic 'playbook', which anticipated early problems we are still facing such as regarding distribution of PPE.  (John Bolton shares credit so far.)  Threehe waffled early on regarding the seriousness of the virus.  Four, he has punted on coordinating distribution of PPE and left state governors to solve a problem within the confines of a market-orientation when the nature of the problem required federal regulatory (i.e. non-market) leadership in light of various positive and negative externalities, timing constraints, and information asymmetries.  Five, according to The Atlantic, Trump has also had trouble with infighting within his administration.  Six, he continues to waffle on when to open the economy, which is a bizarre question in the first place.  People are not simply going to rush out to resume ordinary life.  To paraphrase Mark McClellan of Duke University on Fareed Zakaria GPS on April 12th, you can't push in a string.  Getting the economy going again is a process of confidence building and institutional rebirth - not a button you push.  Our entire way of life is on trial, as I will better explain in part 2.

Trump needs to coordinate with his health and economic experts along with governors and develop an interdisciplinary game plan with benchmarks on when to augment lockdowns based on concrete epidemiological intelligence - which is precisely what Angela Merkel is doing.  It's very hard work with many moving parts and very high stakes.  But it's his fucking job.  Many of his failures perhaps arise from his willingness to cut budgets for the CDC and NIH due to a prior disinterest in pandemic preparedness.****

* I have a great deal of ambivalence towards vaccines.  I do have concerns about vaccine conspiracies.  As for a matter of state policy, I think the government needs to invest and coordinate in developing a vaccine.  I approach this question very honestly.  It could cost my life or that of others.  And I could be called a free-rider in a post-COVID-19-vaccine era.  But I can't take responsibility for everything.  I believe we are all in this life together and need to make informed, free choices in our lives and face the consequences in this life and the next.  As I said, I believe in various method to 'harden' oneself.  See part 2.

** As a recent Lancet article, put it: the "first wave of COVID-19 outside of Hubei has abated because of aggressive non-pharmaceutical interventions.  However, given the substantial risk of viral reintroduction...close monitoring of Rt and cCFR is needed to inform strategies against a potential second wave".  Rt is the illness reproduction rate.  cCFR is the fatality rate. 

*** I write on what 'hardening' of ourselves might mean in part 2.

**** I don't explicitly include testing among his failures - though I probably should - because the CDC is in part to blame for sending out testing kits that didn't all work, which perhaps reflects recent funding problems they have face, which re-implicates the Trump administration.  I choose not to include it as a chicken-and-egg matter.