Assessment of COVID-19 Global status on the Way to Recovery

                                                                                                   IG, SF April 2020

Assessment of COVID-19 Global Status on the Way to Recovery

Summary: proceed with extreme caution; the more I study, the less I know.

Today is Sunday, April 18, 2020. We, in our extended family household of three generations in San Francisco, have been under shutdown due to COVID-19 since March 11. That is over a month and now it is time for me to assess where we are and how we are going to get back to normal.

This pandemic is global. Every country is infected. This infection can be slowed down, but thus far it has not been stopped. Yes, a region, a country, a state, or a town can be isolated, but thus far no one succeeded in keeping the virus out or locking it in.

This virus is very contagious. It moves from people to people unstoppably. The amount of pathogen needed to pass the illness on from an infected person to someone not yet infected is not known, but it is believed to be small. A distant sneeze does it.

It is possible that a small community could shut itself down and isolate itself from the outside totally. Combining such isolation with a very strongly enforced internal segregation of all suspected infections may stop the spread within the community. But such isolation would need to be enforced as long as the rest of the world still has infections.

In general, from a global perspective, lockdown, shutdown, or social distancing as it is commonly referred to, definitely works. It slows down the spread of the contagion but it does not stop it. Lockdown helps to relieve the surge load on healthcare facilities, but currently it is not known whether it does, or does not, reduce the total number of patients that will need to be treated over time. After some delay, Wuhan was shut down, but today the entire world is infected. Will Wuhan and China experience a second wave? As of now, we do not yet know.

Slowing down the spread (or flattening the curve) is extremely important to prevent unmanageable peaks in hospitalization and deaths. The need for and establishment of emergency hospital facilities to deal with the pandemic-caused overflow in China, the USA, and elsewhere have been well documented and publicized. Also, images of emergency temporary storage of the dead in refrigerated trucks in NY City have been widely published. To emphasize and quantitatively illustrate the overflow issue, as a quantitative global reference estimate for deaths due to normal causes (i.e. without of, prior to, COVID-19) I use 10 deaths per 1,000 people per year. The actual number varies from country to country and it depends primarily on the demographic age distribution and the available health care. My global reference translates to an estimate of 1,000 deaths per million people per 0.1 years (0.1 year is about the time that the local spread of the virus infection levels off with lockdown). NY City had the worst coronavirus spread in the USA and registered about 15 thousand deaths versus my reference estimate of 10 thousand “normal deaths”. In the entire USA, the virus deaths are 35 thousand, versus my reference estimate of 330 thousand due to other causes. We now believe that the spread is slowing down. Even if we assume that before the end of the year the total number of deaths will double, in the US we will have less than 100 thousand deaths due to COVID-19, versus my reference estimate of 3.3 million deaths due to other causes. Thus, it appears that the probability for most people of being killed by the pandemic is small in comparison to other causes, but the short term load can easily overwhelm all public caregiving facilities. 

There are two known ways to stop the spread of the virus and return to normal life. The best and surest way would be a preventive vaccination. Another is to achieve herd immunity.

Today there is no preventive vaccine available to the public, but several major efforts to develop one are underway. Developing, testing, and then manufacturing and distributing on a large scale such a vaccine is expected to take well over a year. Thus return to normal life based on protection through a vaccine is likely to be two years or more off into the future.

Herd immunity means that sufficient numbers of people developed immunity, i.e. have COVID-19 antibodies, for the spread of the virus to be no longer a public health concern. In the absence of a preventive vaccine, this is our best hope for a safe reopening of the general shutdown, though it will likely be partial reopening. But, if it can be safely done, living under a partially opened shutdown is much preferred over living under the current total one. There are two fundamental questions that need to be answered as prerequisites for a safe partial reopening: 1) do we have a widely available and reliable test system, both to rapidly diagnose new cases and to continuously verify/monitor the immunity of the segment of the population protected by antibodies; 2) do we have a sufficient degree of herd immunity to avoid reigniting widespread infection?

The answer to the first question is a definite no; we do not have a reliable test system available to the general population. And this is a disgrace! We can go to several websites and easily order a remarkably accurate analysis of our heritage encrypted in our genes. But, we have no broadly available easy access to reliable detection and analysis of  COVID-19 genes infecting our bodies and whose genes are encrypted into our bodies. Likewise, we have no general access to testing for our antibodies that indicate that we were infected and may be immune, at least temporarily. The required knowledge is in hand but the execution is missing.

Tests need to be performed for three reasons.

1. Diagnosis of asymptomatic people. Do they have or not the virus that, if they have it,  they could pass on to others?
2. Diagnosis of people with flu-like symptoms. Is it COVID-19, or only a seasonal/other flu?
3. Antibody testing of everybody regularly to track and manage the protection of the public against the virus.

As of today (April 18, 2020), diagnostic tests as per 2. above are available for patients in the US in hospitals and upon primary-care physician recommendations at test facilities. The other two tests are not available to the general public.

We do not fully quantitatively understand the details of this pandemic. We do not even know what fraction of the population has been infected, thus our death rate numbers are pure estimates, more like guesses. We know that social distancing, and thus general lockdown works to slow down the spread. However, we don’t know whether the observed slow down is a sign of the pandemic ending or are we going to face a resurgence, especially if we relax the total shutdown.

As I tried to learn about the details of this pandemic I was shocked by our lack of knowledge, lack of preparedness, and lack of systematic response at the national and global levels. In fact, I felt that the more I studied, the less I learned, and the less I knew.

So, what does all this mean as we move towards relaxing the total shutdown? Clearly, it will have to be, it can only be, a very carefully managed partial shutdown.

Till we have a reliable and widely utilized vaccine, the threat of recontamination and the potential of restarting the pandemic are real possibilities. In fact, unless an effective, well organized, and locally fast-deployable “instant” full lockdown system is implemented, the recurrence of the pandemic is not only possible but probable. Social distancing under full lockdown is effective, especially if no one in the community violates it. As currently envisioned, as some businesses and other activities restart with some form of partial lockdown, social distancing will be too difficult to enforce fully. Unless the total community is protected by antibodies, i.e. the community achieved herd immunity, reinfection is highly likely. Furthermore, if the community is not isolated from other communities and herd immunity is not globally established, reinfection is even more likely.

Thus, as we move from the full to the partial shutdown, reinfection can be regularly expected. The only currently known response is the total shutdown and sealed-off isolation of the affected and isolatable community from other communities. The affected communities include all communities whose members may have been in contact with individuals who are infected, as well as those that can not be fully isolated from the affected one. Thus, the smaller any individual’s contact area is, and the smaller the isolatable community is, the easier it will be to contain a community’s loss of immunity and its recovery in case of reinfection.

For starters, in the partial lockdown, only very limited freedoms of movement and gathering can be anticipated. With no vaccine and no large scale testing for immunity, we can only hope for some degree of herd immunity; based on this hope, only a very cautious opening of the total shutdown should be put in place, such that upon any sign of the resurgence of the pandemic total shutdown can be promptly reintroduced. Also, to reduce the chances for such a recurrence, all person to person contacts will be limited by distancing and facemask requirements.

If and when broadly available antibody testing is put in place that allows continuous assessment of the status of herd immunity and also of changes in individual immunity will be possible. Then more opening-up, in general, can be anticipated, but still subject to rapid lockdown and isolation of communities where a resurgence of infection is measured.

Return to what was considered normal life in 2019, prior to the pandemic, is likely to occur only after a vaccine is broadly available. This probably will not occur before 2022. And even then it will be a new normal. The pandemic will have left behind major social, political, and economic changes. This is a global war against an invisible enemy. Freedom to travel and gather will return, but society around the world will be changed, much like it was changed after the brutal trauma after World War II. Will the USA resume leadership in that new world order, or will China take the lead? I don’t know, thus I can only hope for the best. 

In the USA, the pandemic is going to leave behind major economic damage: increased unemployment, increased national debt, and shrinking GDP. Many small businesses are likely to fail, but only a few, if any, of the majors are likely to go bankrupt. Capitalism is going to survive but with more socialistic elements integrated into it. General healthcare and national public health institutions will be strengthened. Globalization is likely to continue, but local supply chains will be strengthened to deal with pandemic-like disruptions of the global supply chain. Income taxes will increase. Income and wealth inequality will receive more scrutiny. Industrial automation, with a strong emphasis on the service industries, will increase significantly; the pandemic taught us that machines don’t get sick and continue to work well under a shutdown. There will be fewer jobs. Unlike in previous times when manufacturing offered employment to those who were no longer needed in agriculture and subsequently the service industry picked up those not needed in manufacturing, there is no new industry to employ all the people who are replaced by automation in the service industries. The new full employment figures will be based on a lower labor force participation rate and on a higher number of unemployed workers than the pre-pandemic 63.2% and 3.6% (BLS figures for 2019). A guaranteed minimum income for all Americans may be required to maintain societal stability.