So that’s why Trump sounded so different at yesterday’s press conference. Per the Times, researchers at the Imperial College in Britain shared their model of the epidemic with the White House task force over the weekend.
It’s not great.
Scott Gottlieb, the former FDA commissioner who’s served as a sort of “shadow czar” on social media for coronavirus, has used most of his public comments to focus on glimmers of hope. Every time a vaccine takes an early halting step, every time some pharma company touts progress on an antiviral drug, every time there’s a measurable increase in U.S. testing, he highlights it. He’s trying to reassure people while also warning them that there’s rough sledding ahead: Expect a bad six weeks at a minimum, he’s been saying, before hopefully some sort of temporary reprieve.
Two fundamental strategies are possible: (a) mitigation, which focuses on slowing but not necessarily stopping epidemic spread – reducing peak healthcare demand while protecting those most at risk of severe disease from infection, and (b) suppression, which aims to reverse epidemic growth, reducing case numbers to low levels and maintaining that situation indefinitely. Each policy has major challenges. We find that that optimal mitigation policies (combining home isolation of suspect cases, home quarantine of those living in the same household as suspect cases, and social distancing of the elderly and others at most risk of severe disease) might reduce peak healthcare demand by 2/3 and deaths by half. However, the resulting mitigated epidemic would still likely result in hundreds of thousands of deaths and health systems (most notably intensive care units) being overwhelmed many times over. For countries able to achieve it, this leaves suppression as the preferred policy option.
We show that in the UK and US context, suppression will minimally require a combination of social distancing of the entire population, home isolation of cases and household quarantine of their family members. This may need to be supplemented by school and university closures, though it should be recognised that such closures may have negative impacts on health systems due to increased absenteeism. The major challenge of suppression is that this type of intensive intervention package – or something equivalently effective at reducing transmission – will need to be maintained until a vaccine becomes available (potentially 18 months or more) – given that we predict that transmission will quickly rebound if interventions are relaxed. We show that intermittent social distancing – triggered by trends in disease surveillance – may allow interventions to be relaxed temporarily in relative short time windows, but measures will need to be reintroduced if or when case numbers rebound. Last, while experience in China and now South Korea show that suppression is possible in the short term, it remains to be seen whether it is possible long-term, and whether the social and economic costs of the interventions adopted thus far can be reduced.
“Mitigation” is what the UK was planning to do until this study made the rounds within Boris Johnson’s team and caused eyeballs to pop. They’ve now switched to a “suppression” strategy, in line with the U.S. and virtually every other country. If the Imperial College’s model of the disease is right, though — and that’s a big “if” — then suppression doesn’t hold the disease at bay once it’s lifted. We’d need an indefinite lockdown, a.k.a. economic suicide, until an effective treatment is available, which could be more than a year away. Social death by contagion or social death by economic depression: It seems like the task for policymakers right now is finding the “optimal” balance between those two that’ll result in the least possible amount of human misery, knowing that the misery will be incredibly vast no matter what they do.
Bear in mind, this is how things look with some suppression measures already (belatedly) instituted:
NEW: NY Gov. Cuomo says expert projections show expected peak of coronavirus cases in New York in 45 days.
Cuomo says state will need 55,000-110,000 hospital beds and 18,600-37,200 ICU beds at projected peak, and that state currently has 53,000 hospital beds and 3,000 ICU beds. pic.twitter.com/PiaQ8IOHqI
— NBC News (@NBCNews) March 17, 2020
You could theoretically stamp out the disease entirely if you had perfect suppression for, say, a month. If everyone in the world stayed home, the disease couldn’t spread. Those infected before the lockdown would get sick during it, would either recover or go to the hospital and be isolated while they recover, and at the end of the period the virus would be extinguished in all carriers. We … do not have perfect suppression, needless to say. Perfect mitigation could also work, I suppose: If some small fraction of the population were able to go on as usual while the rest, including and especially the vulnerable, were perfectly isolated, that small fraction could be treated without crushing the health-care system. Then they’d be immune — hopefully — and some other small fraction would be allowed to go on as usual while the remainder stayed isolated. Britain was planning to try some variation of that with younger, healthy people, but the volume of sick even among that less vulnerable group would overload the medical system according to the Imperial College study. And needless to say, we don’t have perfect mitigation either.
My mental picture of the choice we’re facing right now is standing on a train track with a train about 1,000 feet away. At a moment like that, you don’t think; you jump off that track before you’re creamed. So we’ve jumped by instituting social distancing — but now we’ve landed on a new train track with a second train coming at us around 2,000 feet away. That’s the epidemic once “suppression” measures are lifted. And now we have a broken leg in the form of a massive economic slowdown via our “jump.” What do we do now? We can jump out of the way of the second train too by keeping the suppression measures in place (assuming people agree to continue to follow them), but that’ll land us on a third track with a third train 3,000 feet away. And now we’ll have another broken leg in the form of even more economic pain. The White House is already talking about an $850 billion(!) aid package to prop up failing businesses. How big will the package be when we’re on track two? Track three? At what point are we in the midst of a major global depression, which will kill a lot of people even if the virus hasn’t by that point?
At some point in this thought experiment we’re maimed and dead either way. The only thing that’ll save us is derailing the train. Gottlieb is suddenly calling for a “Manhattan Project” to develop drug treatments before the onslaught this fall, when any respite we get from summer weather (assuming we get any respite at all) is over:
We must get a drug and eventually vaccine. We can have treatments, antibody prophylaxis, point of care diagnostics for early detection by fall. That must be focus. #COVID19 doesn’t go away. Initial wave will run course into summer but it’ll be back until our technology stops it. https://t.co/N4QRTBrdJe
— Scott Gottlieb, MD (@ScottGottliebMD) March 17, 2020
Government leaders should launch major effort to get therapeutic to #COVID19. Where is sense of urgency we need? This isn’t ordinary moment. An antibody prophylaxis that protects healthcare workers, elderly, immunocompromised has lot of near term promise. https://t.co/3tijyjF0q6
— Scott Gottlieb, MD (@ScottGottliebMD) March 17, 2020
As I understand it, there are three layers of potential treatment. One is the “antibody prophylaxis” Gottlieb mentions, which is where antibodies are taken from the plasma of people who’ve fought off the disease and developed into a treatment that will provide short-term immunity, first and foremost for health-care workers. Regeneron is planning to start human trials on that by early summer. The next layer is antiviral drugs, medicine that can be administered to critically ill patients to squelch the virus after they’re hospitalized. The leading candidates for that are remdesivir and chloroquine, a drug developed to fight malaria. (Apparently favipiravir also looks promising.) The third layer, of course, is the holy grail, a vaccine. That’s in the works too. But all of these things take time and we don’t have time. How do we speed up development and distribution? Is it chiefly a logistical problem, which may be intractable, or a regulatory problem, which can be addressed? If the Imperial College study is accurate, we may shortly reach a point of such despair in containing this that people will beg for drugs like remdesivir regardless of what unknown side effects they might bring. What do the feds do then?
Maybe Regeneron will be ready with its prophylaxis by fall. Maybe we’ll have the masks, protective gear, and ventilators we need by then. More importantly, maybe we’ll have the scale of testing we need nationwide to quickly identify coronavirus patients as they present themselves at the hospital in October and beyond. That’ll reduce the pressure for a nationwide lockdown but it won’t solve it completely because the disease can be transmitted by asymptomatic carriers. If we don’t have this stuff, we get hit by the train. Even if we do have it, we end up with one or more broken limbs. There’s no time to waste.
“We really need to put a lot of effort behind” a point of care diagnostic says @ScottGottliebMD on expediting testing for #COVID19. “I don’t see the sense of urgency that I believe we need.” pic.twitter.com/4vy589ZzQI
— Squawk Box (@SquawkCNBC) March 17, 2020