Coronavirus: Choose Global Action Faster-Finally Care For Loved Ones




Masks can reduce Covid 19 spread by 40%-study suggests

      Masks appear to be a very cost-efficient                   method to curb the coronavirus              spread.
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Ballad Of A Thin Man - How To Ignore Your Government and Think About COVID-19 For Yourself

By Ken Evoy

Contents

Foreword page 3

Disclaimer page 3

Introduction page 4

Why Is This Important page 5

View of the Top page 7

Takeaway #1 page 8

Help! What Do I Do? page 10

Takeaway #2 page 10

Takeaway #3 page 11

The Easy-Magic Solution page 14

There’s More! Page 15

Takeaway #4 page 22

Takeaway #5 page 23

Takeaway #6 page 27

What Are the Key Elements to Defeat SARS-CoV-2? Page 29

The Big Six page 29

Takeaway #7 page 32

Simple Summary page 34

Who Puts This All Into Place? Page35

Takeaway #8 page 39

A Thought Experiment in Exponential Growth page 41

China Blame? Page 51

So How Did China Do It! How Should the Rest of the World Do It? Page 54

What’s the Deal About Herd Immunity? Page 57  

Reliable Updates page 59



Foreword

I originally wrote Ballad Of A Thin Man - How To Ignore Your Government and Think About COVID-19 For Yourself as a pair of forum posts out of concern for Solo Build It! members. Requests from the SBI! community for a document that they could share with family and friends convinced me of the need to create this PDF.

I wrote the forum posts from March 12 to March 20, when I published them. So some of the numbers have changed.

The lessons, however, remain valid today. The primary lesson is that governments tend to misinform and mislead, sometimes deliberately.

Use this document to protect yourself and your family from COVID-19. Use it also to develop your critical thinking skills about what your government is telling you and doing “for” you.

Ken Evoy, M.D.

Disclaimer

This document is not intended as either medical advice or legal advice. Please contact a medical professional if you experience any symptoms you think are related to COVID-19.

The decisions you make based on this document are your responsibility.

Introduction

By now, anyone who watches even the most mass-market NBC Nightly News knows that “something is happening here”...

https://youtu.be/IBsefkZjNW0

 

To continue that lyric from Bob Dylan’s song, “Ballad of a Thin Man”...

“but you don’t know what it is, do you, Mr. Jones.”

The goal of this essay is to help you know and understand what “it” is...

It’s staggering that most people still know only enough to be afraid, but don’t understand enough to “know what is” and what to do. And that’s the goal of this piece — if you take the time to absorb it, and recognize where your particular locale falls on the timelines and scenarios, you’ll know what to do

And that’s important because most people will go along with the herd. At times, a herd is smart. In times of panic, though, often not so much.

It’s staggering that governments must understand by now, from the scientists, how to stop this virus. But instead they treat the symptoms, not the underlying problem of, well, you know... a pandemic!

Why Is This Important

A member of the SBIer community asked an interesting question a few days ago...

I wondered what your take is on the British approach — to let the wave wash over them, as it were, in order to build up herd immunity more quickly.

I actually have it from a serious epidemiologist that this is the way to go — if you can stomach it.

As I started to dig into the reply, I decided to widen her question to this...

Which approach is ideal? And what should you do if/when you realize that your leaders aren’t on that ideal path?

The deeper I got, the more resentful I became.

“Our leaders really suck.”

It’s not like that was an epiphany or anything, but only a few have managed this world-changing problem well.

I continued talking to myself...

“Time’s running out for most of us, and if there is one thing in this world that you can’t waste when dealing with a problem that grows exponentially”...

It’s time

It’s alllll about time.

Time is, as every good solopreneur knows, the issue to master — prioritize optimally, right? Depending on what time it is, the macro solution varies. Let’s see how (badly) our leaders are doing. 

First, a quick answer to that SBIer’s question...

I wondered what your take is on the British approach — to let the wave wash over them, as it were, in order to build up herd immunity more quickly.

I actually have it from a serious epidemiologist that this is the way to go — if you can stomach it.

The answer to that depends on the context. But we need to look at this from a much larger perspective because the answer changes, all depending on the time!

In other words, there’s a time to think about this. That time is generally near the “out of control” phase (way over at the far right of the power curve). Even then, though, there should be some provisions that were left out by Boris Johnson, Prime Minister of Great Britain.

With that intro over, here we go...

View of the Top

I’ll start this with what I really don’t understand (or perhaps I prefer not to) ...

Why does a government throw $$$ at a virus? What makes them think that raining “helicopter money” from above will fix the economy when the problem is driven by a microbe (and, just as importantly, the population’s terrorist-level fear of that bug)? 

I must have missed that class in macro-economics (or was it microeconomics?). But I don’t foresee most folks running out to blow that wad of free money on stuff. Even if they do, even if the markets go up for a day or two after the big political announcements...

The virus doesn’t have a stock portfolio. It’s just happy to have more time to wreak death, doubling in pace every few days. And that brings worse-than-ever news that hits at a gut-fear level. So the markets go right back down, while the virus has doubled its spread.

A quick note...

I’ll be specifically talking about the U.S. government here. It’s not personal. It just happens to be uniquely positioned to be the example...

1.      It’s the world’s largest economy and third largest population, with all the people and resources to solve a problem like this rapidly, especially given its usual inclination to learn from others and improve upon that.

2.      It’s following in Italy’s footsteps and headed toward a disaster that looks like this...

 

https://youtu.be/2kQkTNChr34

3.      It has had more time to avoid the fates of Italy, France, Spain, yet seems determined to follow the same path to a massive death count.

4.      It’s had more time to copy the best of what Taiwan and China (after its initial mis-step) did so well, yet hasn’t.

So, in a nutshell, if an impending failure can happen there, it can happen anywhere, wherever you are as you read this. The lessons here apply to you, wherever you live. And that brings us to...

 

Takeaway #1

Understand your enemies — virus and ignorance. It’s the only way to brave self-serving government misinformation and to resist the herd instinct of everyone else.

Don’t depend on your government. Act on your own, based on understanding the principles laid out here. Spread the word to help others understand and do the same.

You’ll be amazed what folks don’t know, as well as who doesn’t know it. Such is the damage of misinformation from leaders. For example, I was floored at how cavalier/ignorant my own sisters were...

And I’m not dissing my sissies (I’d never do that! ). Normalcy bias is hard to overcome. It’s impossible to emerge from the fog if you’re not being well informed. The smartest people you know may be paralyzed — until they hear it from you in clear, clean words. https://en.wikipedia.org/wiki/Normalcy_bias 

We’ve seen proof of that in the feedback in the SBI! Forums, how some of the sharpest SBIers were moved to action. They had a high level of suspicion, even knew that something big was coming, but that alone is not enough to break normalcy bias.

Inform, teach. Be part of the solution.

So now that I’ve put this weight on you, you may be thinking...

Help! What Do I Do?

I’ll start with the second takeaway.

Takeaway #2

Assume everyone is ill. Assume you are, too.

You’ll do an awful lot right if you remember just that. After all...

If you know just a whit about the common cold or Influenza, you know to keep your distance (to avoid catching and spreading), for example. 

Well, that’s more important now than ever because the extra info here is that this virus is both sneaky-contagious (no need to feel ill to spread ill) and more likely to kill you! That’s one dangerous mix.

Keep your distance. But make it 10 feet apart instead of 6. That gives you time to put your hand up like a traffic cop and say, “STOP” when a friend approaches you. It also means that you won’t go out at all, except for the necessities (and even then, you’ll know to stock up).

So again, to reinforce...

Don’t wait around to be told what to do. We covered “social distancing” before it was a thing. Now it’s all you hear about — after so many have caught this nasty little surprise due to all the social events, big and small, and including direct personal contact.

Bottom Line: You don’t need to figure out whether your leaders are dumb or evil. Or both. Just know that, with rare exception, they’re wasting precious time, enabling the virus to 2X and 2X again, and again, and again, every 3-5 days (depending on local circumstances).

Takeaway #3

The silent power of exponential growth. It creeps until it leaps.

Imagine this...

Let’s say 1,000 people are sick.

Leaders: “We’re going to cut interest rates by half a percent.” Result 4 days later: 2,000 people are sick.

Leaders: “OK, well then, we’re cutting rates by 1%, down to ZERO.” Result 4 days later: 4,000 people are sick. 

Leaders: “Wow, OK, maybe this is a problem. We’re going to pump up the banking system with hundreds of billions of dollars, up to

$1.5 trillion!”

Result 4 days later: 8,000 people are sick.

 

Leaders: Maybe you didn’t understand that banking stuff. So are you ready? We’re gonna give $1,000 to you. Yes, each and every adult, so that you can spend it right back to big business and taxes to us.” (OK, they didn’t say that last part.)

Result 4 days later: 16,000 people are sick.

Summary of the 2020 stock market crash…

https://en.wikipedia.org/wiki/2020_stock_market_crash

You think you see where this is going, right? Well, sort of. At the time of this writing (March 18), there were 9,000 confirmed cases in the

U.S....

https://www.worldometers.info/coronavirus/country/us/

Go to the exponential growth curve that you see (it’s labeled “Total Coronavirus Cases in the United States”). Next...

Track back to March 6 and click on that dot. How many cases?

319. My story doesn’t look so crazy now, does it? Especially since cases are now at 35,000+ as of the morning of March 23.

The government repeatedly tried to solve a medical problem with an economic solution. I know you know Einstein’s definition of “insanity,” so I’ll just skip to the bottom line...

I n s a n e.

The final kicker in all this…

Remember when Trump said there were only 15 cases, headed toward zero? He doesn’t, either, but I promised not to make this political, so let’s just get to the bottom-bottom line...

On January 30, he said...

“We have it very well under control. We have very little problem in this country at this moment — five. And those people are all recuperating successfully.”

Source (a full list of all the false downplaying statements)…

https://www.nytimes.com/2020/03/15/opinion/trumpcoronavirus.html

If you’re somewhat math-oriented (I am, so you’ll have to bear with me, but it’s worth it — I promise)...

How many times do you multiply 5 by 2 until you reach 9,000? Calculators at the ready, gear-heads, go...

Almost 11 times (10.8, if you want to split hairs). That’s 11 doublings in how long?

•  2 days in January

•  29 in February

•  18 in March (up to the day I wrote this)

That’s 11 doubles in 49 days, or roughly one double every 4.5 days, which fits into the 3-5 day estimate above. Now here’s the most important part of all this...

While the government is fiddling dollars into a fire, the fire is doubling every 4.5 days. (And almost doubled twice again in just 5 days, from March 18 to 23.)

They knew this. 

It’s impossible not to have known.

Given all the evidence around the world, it didn’t take an epidemiologist to understand. Even a garden-variety ER doctor would have this basic knowledge and would certainly know it’s an emergency (I used to be an emergency room doc).

At 5 doubles, it was an emergency. All you had to do was the math. 

So, what’s the solution?

The Easy-Magic Solution

Just stop it at 5. It’s so doable. Heck, take a week or two to twig to it, screw up your courage, and get the right people into place. You’re still only at 3 doubles after 2 weeks. That’s 40 people with CV19. 

(China slammed Wuhan and other locales into the right cure at 400 cases!)

And to heck with the cost...

Throw $1,000,000,000,000 (a trillion!) at those first cases, and it still would be money well spent to eradicate the disease. The cost goes way up if you deny and keep denying the inevitable and then pour gas on the fire.

We’ll see how and why catching it early could have been so easy. We’ll see how China could have chopped off most of the problem by starting just 2-3 weeks earlier.

China deserves a partial pass because it had no idea that it was dealing with a totally “novel” virus. Suppressing it, though, including censuring whistle-blowing doctors, was head-scratchingly, dumb and evil. After that, though — it was a model of how you can quarantine and-manage (not just quarantine) your way out of trouble.

Other countries suffered a mixed bag. Some chose to swipe right, others left. The US had the benefit of a ton of data and results. It coulda/ shoulda fixed it for the bargain basement price of a few million.

At 5 people. If only what Trump said early on was the truth. Because it really coulda/shoulda been.

But wait! We’re not done. In the fine art of the Ginzu Knife salesman...

There’s More!

Hard to believe, but I have a final kicker...

Each person with a confirmed case spins off 50 others with the virus before being diagnosed. Source/explanation (interesting stuff!)...

https://link.medium.com/Zi96DILAV4  

So we’re talking 450,000 people. 

From 5.

Because the wrong stuff was done. And the right stuff was right there for the using, but ignored.

What a ride. And thanks to our leaders, it’s only just begun. We’re many months from wrestling this to the ground, over a year if the right moves aren’t made fassst!

                                                                    Sidebar       

Would you slap me upside my head if I said “Wait, there’s more!” just one more time?

I thought so. That’s why I’m hiding this part in a sidebar. The other reason is that this area is not my forte.

The cost of the government’s inappropriate action has other negative consequences, potentially also in the trillions.

Economic solutions for non-economic problems beget greater economic problems and don’t solve the original, non-economic cause. If I gave you Tylenol to reduce your fever but no antibiotic for the pneumonia that’s causing the fever, how well do you think you’d do?

The economic expenses happen at two levels... the direct dollars that are borrowed (increased debt) or printed (leading to inflation and possible hyperinflation) to throw trillions at the non-cause, and the indirect societal cost of letting things get out of hand. The latter is hard to measure, so let’s start with interest rates as an example of “direct”...

1. The Federal Reserve in the U.S. fired 1.5%-worth of interest-rate bullets that should have been saved to fight the next recession. Now there’s zero room to fight the next recession with that classical go-to move of reducing interest rates. This leaves the nation without one major weapon to fight the next recession. 

How do you measure the cost of a recession that might be deeper than it needed to be due to the absence of being able to cut interest rates? 

Hey! What?

Do I look like an economist?

But it’s “a lot.” LOL.

Or maybe it’s nothing...

It’s possible that economists may consider the interest rate cuts as a “prepayment” on getting out of the recession after the disease is cured (the pre-condition for turnaround).

When people are both well and unfearful, the system will be locked and loaded with super-low interest rates. Consumers will be ready to buy and travel, while companies will be ready to borrow to grow again. In short...

The economy will be ready to zoom ahead faster than ever. SARS-

CoV-2 (COVID-19’s other name) is like a million pound weight holding back a Ferrari, tires burning rubber and ready to take off. Remove the disease and get out of the way!

If that’s right, there are some tremendous investment opportunities coming your way.

Bottom Line: Let’s just call the cost of lowering interest rates a wash, but worth remembering.

i)   CV19 is the main cause of the recession.

ii) The stock market had been overpriced, with lots of stresses in the economy ready to pop at any second. One example is the high levels of debt that companies had built up due to low interest rates....

https://edition.cnn.com/2020/03/14/investing/corporate-debtcoronavirus/index.html

It was becoming untenable, and represented a serious risk to cause or aggravate a down-turn in the economy (with or without CV19). Now, though...

The reduction of interest rates and the pumping of tons of money into the system reduce the chances of the scenarios in the above article causing or deepening a recession.

iii)  The government super-revved the engine and stock prices came down to more reasonable levels (they were seriously overpriced before).

iv)  Remove the disease = remove fear and caution. Benefit from all that futile stimulus, still waiting to go.

After interest rates, we have another direct cost to deal with...

2) The U.S. national debt is already at the unfathomable amount of $23.3 trillion. It will grow by roughly $2T (a rough guesstimate on the final cost of the above-mentioned programs to save the economy and stock market, but not fight the disease).

This may be a prepayment, too, but right now, it’s an expense that’s going to push the deficit up, assuming the program is executed fully.

Note: Just as impressive is how Trump has grown the debt from $20 trillion at the time of his election to $23.3 trillion before any of this came along to change the world...

https://www.worldometers.info/us-debt-clock/

How does one rack up $3.3T of new debt during boom times? In fact, he’s just getting started. His plans are estimated to take the budget to $28.5 trillion by the end of his second term....

https://www.thebalance.com/trump-plans-to-reduce-nationaldebt-4114401

Note: We all know, though, that the real numbers end up way worse than projections that are 5 years out. Consider that Trump had promised to eliminate deficit spending...

https://www.newsweek.com/trump-deficit-debt-cbo-dataobama-1463802

The reality is that far-into-the-future estimates are “magic-monkey numbers pulled from their, well, you know.” And they never err on the low side. Let’s assume that he’s equally as far off during the remaining 5 years, so add $5T to his estimate. 

Now we’re at $33.5 trillion.

So where were we? Oh yes, we’re adding $2T to that, for a total of $35.5 TRILLION.

To quote the man...

“It’s going to be ‘HUUUUUUUGE.’”  

And yes, it really is going to be much more because we have not yet calculated the cost of the real solution to our medical-driven problems. And the problem is now much bigger and more complex than China faced.

The real solution is draconian, but necessary. The economy takes another hit, but this time it’s to end the horror story. China has already gone through the slowdown of the economy that happens when you shut everything down (the right move that will cure the problem — more below).

So how much does that cost a country? Let’s take a peek at China’s experience. The total containment (with sophisticated process) worked, but at a cost, both financial and social...

https://edition.cnn.com/2020/03/16/economy/china-economycoronavirus/index.html

https://www.nytimes.com/2020/03/07/world/asia/chinacoronavirus-cost.html

But it gets the job done...

The goal of a total shutdown is to stop the virus from spreading. We’ll cover how that works below. You don’t just close ingress and egress of people. You have to process, sort and treat appropriately. That is absent in the U.S. 

And that’s a shame. You know why by now...

The sooner you shut down and run a process that eliminates the virus, the quicker and better and cheaper. Otherwise, you have to find and deal with geometrically larger populations of… “Asymptomatic Infections” — have the virus, but no symptoms. 

“Symptomatic Infections” — treated according to how ill they are.

Sick, but from Influenza — or a bad cold or bacterial pneumonia.

Well — no infection, not ill.

So, the sooner you can sort and treat, the smaller the job, the sooner the area can get out of their homes and back to work and play. Sadly, containment is no longer possible...

The U.S. is in a much worse place than China was when they put their total shutdown in place (9,000+ cases vs 400 in Wuhan — and now 35,000+). On top of that, Americans are more mobile, etc.

So the U.S. cleanup will be an order of magnitude bigger and longer than China’s. It’s hard to say how much it would cost to shut down a country completely.

Note that no dollar cost was included in the articles above. But let’s say that the U.S. does introduce a total country shutdown as advocated by Bill Ackman, a respected and sharp-thinking investor activist...

https://www.cnbc.com/amp/2020/03/18/bill-ackman-pleads-to-

trump-to-increase-closures-to-save-the-economy-shut-it-downnow.html

How much would that cost? OK, as a non-famous and rather ignorant amateur economist (as of this moment!), I’ll take a stab… The size of the 2020 US budget is $4.8 trillion, with only $3.8 trillion of revenue, for a deficit of roughly $1T. Now imagine a month of total shutdown, paid for by the government.

Let’s ballpark that the government loses approximately $300 billion of income (roughly 1/12 of revenues for the year).

It also spends an extra $1.2T to cover all the expenses of a country with no income.

And finally, it spends $500B to fund a massive program that sorts, diagnoses and treats every man, woman and child appropriately.

Add that up = around $2.0 trillion. Yes, I fudged a little to keep the number nice and round, but it seems reasonable given the amount of money the government is willing to throw at the non-problem (economic) part of the problem already.

Add that to the $35.5T and we’re at $37.5T total debt by the end of Trump’s second term.

And we’re still not finished on the costs of the delay of inaction...

1)   The stock market: a roller coast that had record down days and has erased more than $10 trillion of wealth. That does not count as a federal expense, but it’s $10T out of investors’ pockets, and that means less spending...

https://markets.businessinsider.com/news/stocks/stock-marketoutlook-2016-trump-win-gains-erased-coronavirusrisks-2020-3-1028991585

2)   The U.S. is now in a bear market and the general consensus is that a recession will be seen to have started in March. How long it lasts depends on how long it takes to tackle the medical problem at a consistent and determined national level. 

We’re already way too late, with no concrete national plan on the verge of starting, including total shutdown and other policies (more on this below).

But it’s fair to say that the upcoming cost and pain to everyday people is going to be enormous. We’ve factored this in above, but further delay could push that north.

3)   Until then, why would someone who is not buying much now, out of fear and shock, suddenly start spending? No, the core problem of a terrorist virus has to be resolved first.

Until that happens, a deepening recession continues to cost the nation an unimaginable amount of money...

$37.5T in debt and counting by the end of Trump’s second term.

OK, if you skipped that sidebar, you’re fresh and don’t have a headache. If you read it, I apologize for the bilateral pain in your temples! And either way, we’re at a total deficit of $37.5T by the end of Trump’s second term, if he’s re-elected.

Takeaway #4

See through the B.S. (It’s everywhere.)

You now know the principles to use with your shiny new BS-o-meter. For example, whatever the government may say or do next, ask... 

“What does this have to do with stopping SARS-CoV-2?”

For example, instead of passively swallowing “the news” (see the YouTube link below for a sample of NBC news), I hope you will now be critical, even posting on Twitter.

https://youtu.be/IBsefkZjNW0

What makes this government think that money is going to slow down SARS-Cov-2’s torrid exponential growth and surging mortality rates? SC2 is delighted to see everyone wasting time, because each wasted day means even more unchecked exponential growth, making the solution exponentially more difficult.

Speaking of time, let’s move on to the next takeaway...

Takeaway #5 

Time is not linear when it comes to CV19. 

Be aware of time. It’s critical to understand how exponential growth works.

In other words, don’t count like this...

1       2   3   4   5 Instead, it’s...

2       4   8   16   32

As time passes, the problem gets geometrically bigger. It sneaks up on you. No one sees it until it’s “too late.” Then everyone sees it (and toilet paper sells out).

Trust me, if mad rushes for Purell and Charmin have not occurred where you live, stock up now. On everything.

We also never see that magical “supply chain” that everyone suddenly talks about (always in the context of it breaking down). But a nasty virus is on a collision course for it. It’s not far from exploding onto your scene, wherever that may be. 

Another important point about time...

Every government has had the benefit of time, except China. It was the first. More subject to the normalcy bias than any other country-victim, it made mistakes early on. And not all were of the innocent variety.

But China recovered just in time and set a template for others to build upon. It bought us time.

Our leaders should have absorbed those real-world lessons, in realtime. China’s results were real proof of what everyone else needs to do.

Recognize what constitutes wasting of time. For example, as I type this at 7AM on the 19th, the first notification of the day flashes on my tablet...

China had no new locally transmitted cases on March 19th, for the first time since it started.

Italy recorded 475 deaths on the 19th, its highest number since the crisis began (and now closing in on 1,000 per day).

Mexico announced its first death, but few containment measures.

Think about each of the countries above in terms of time and how they use it. This should now be straightforward!

1.       China’s containment program is working. No new cases, just a few weeks after an enforced quarantine.

2.       Italy, with its highly social culture, started way too late. Strict countermeasures show no sign of improving. See the first power curve (“Total Coronavirus Cases in Italy”) at…

 

https://www.worldometers.info/coronavirus/country/italy/

Compare to the U.S....

https://www.worldometers.info/coronavirus/country/us/

Yes, the same path. The U.S. is still showing a clear power curve (meaning “exponential growth”). The U.S. has done little testing anyway. 

Meanwhile, part of the reason that Italy has such a high fatality rate is that they test people with symptoms of a coronavirus infection, while, say, South Korea has been testing basically everyone since the outbreak became apparent. Consequently, Italy will pick up older, sicker patients (relative to young and well).

This has important implications. For example, if the disease spreads mostly within a younger population, there is less chance of hospitals being overwhelmed. The inverse applies to Italy — spreading among older patients could end in hospitals being overwhelmed.

This is an excellent example not only of the importance of testing, of the information that you can get from it, but also better knowledge of CV19’s impact on a country.

Bottom line: Trying to manage CV19 without much testing is like driving a car without vision. Thankfully, the U.S. is about to roll out mass-testing.

What other quick takes?

Countries are closing their borders like mad. Almost 220,000 infections have been confirmed worldwide, with the death toll over 8,800. That’s 20,000 and 800 more than the day before. (Those numbers are now 359,000 and 15,433 globally, with 100,000 recoveries.)

Those mounting numbers, still growing exponentially in most countries, say it all. The fact that all European nations are doing the same thing is a handicap. And Europe is kicking in a trillion euro or so, too.

Hey, if it’s good enough for the U.S. to not affect the viral spread, it’s good enough for the EU.

The virus (and the sick) don’t seem to care about free money. So...

Instead of focusing on pushing the stock market back up, instead of trying to fix the economy with free money, attack the actual problem, the virus and its accelerating rate of spread. That can only lead us to one conclusion...

We’re now out of time. 

Takeaway #6

SHUT EVERYTHING (AND EVERYONE) DOWN AND LEGISLATE A NATIONAL DISTANCING AND SELF-ISOLATION PROGRAM.

Sorry for all the YELLING, but this is so obvious...

It’s not only basic economics, it’s basic medicine.

It’s too late to use this and expect to contain CV19, but a vigorous and disciplined program can still slow it down, easing the hospital overloads that we’re already seeing in some locales.

This program must include fast, free and intelligent testing, rapid sorting out (flu vs a cold vs pneumonia vs CV19). Quarantine the ill, together, not at home (where they’ll infect loved ones). In short, and for the first time, aim a massive, motivated program at the disease itself.

And even shorter: Fix the disease, not the symptoms. 

The only way to get on top of this problem, as I talked about when I began, is to institute draconian measures that would normally not be considered in the free world.

Many think that China was only able to do what it did because it’s a dictatorial state. That’s true, but only to a certain extent, because it also got good buy-in. People were scared and wanted to be safe.

Without buy-in, it’s not enough to try to force people to stay at home. Nor can you force people to maintain a safe distance from everyone else. Clear, transparent communication goes a long way to getting that trust.

You need to manage that reduced mobility with a smart, disciplined program, which we’ll see shortly. It’s not necessary to replicate successful programs to a tee, but it is necessary to understand that this is the most significant threat of the century to the world (OK, the Spanish flu was worse, but it had 2 waves).

If you missed Bill Ackman’s case for shutting it all down, the whole country, watch it now. His passion and arguments are compelling...

https://www.cnbc.com/amp/2020/03/18/bill-ackman-pleads-to-trumpto-increase-closures-to-save-the-economy-shut-it-down-now.html

It gets the big picture right. Certain parts can be improved (e.g., you don’t keep sick people at home with well people). Whatever, it’s critical to just get started...

What Are the Key Elements to Defeat SARS-CoV-2?

The virus’ key to success is fast and sneaky doublings. So leaders must check their egos and focus on finding it, slowing doublings down, and leaving it with no place to go. 

They must jump right past denial and partisanship, etc., to act fast to nip exponential growth in the bud. Successful countries do that and mix in a blend of the following key components in varying parts...

The Big Six

1) Fast, cheap or free testing. 

I could spend many paragraphs on how and why testing is so important. Instead, this article says it all...

https://www.theguardian.com/world/2020/mar/18/scientists-saymass-tests-in-italian-town-have-halted-covid-19

They tested every person in a town, and learned that asymptomatic carriers are the big problem. Once they were isolated, they eradicated the disease from the town. Period.

To make that work large-scale would require a total shutdown of a region or country. No one in or out while you find all the no-symptom spreaders and isolate them.

2)    A solid action-plan for what to do with the ill. 

You have someone with a positive test. This part of the program ranges from meticulous contact tracing to gathering them all together where they can’t infect the healthy, and where medical staff don’t have to constantly de-gown and re-gown (all they see is patients with the same disease), and they develop expertise in assessing, triaging and treatment.

3)    Clear, transparent, no-BS, yet reassuring communication. 

While reassuring is nice, it can’t sustain when it’s based on falsehoods. Simply knowing that your premier or president really does have things under control and that you’ll be hearing the truth is reassuring enough.

China’s Xi did calculable harm by denying CV’s existence, disciplining doctors who went public, etc. Without defending him, it takes time to connect dots and conclude “new bug.”

Once committed, the full program rolled out with mind-boggling success. But if he had skipped the early nonsense, it’s estimated that he could have reduced this coronavirus to “disaster averted.”

Trump did incalculable harm by telling us all that there were only 15 cases, heading to zero, by saying it was like the flu, etc. For a while, it was clear that even Canadian friends of mine had believed his various inaccuracies.

There was no excuse for this, since he had loads of data. Scientists knew where this was heading. 

He was also off-topic with bizarre messaging, for example about his genius uncle. He claimed, therefore, that he had a knack for this, too. Sheesh, that’s hard to listen to when the stakes are low

These critical time-losing communiques instill false confidence in people (who therefore act far more loosely, becoming early fodder for a virus looking to establish a foothold).

Instead, deliver frequent, open, evidence-based (i.e., scientific data) messaging about what’s going on and why it’s a danger, even in the earliest of days (when you might look silly if wrong, although you should know enough to know that’s not the case).

A leader who communicates well and honestly leads citizens with reasonable order through tough times. The rest ultimately go from “false calm” to “panicked reality.” What do you do?

Ignore the messaging and believe the principles outlined here. We were stocked up with months’ worth of supplies well before anyone we knew, both in Panama and Anguilla. There’s nothing “smart” about it — we just used the principles here.

The next three must be legislated and enforced. There’s no partway or some-of here. This Chinese expert made no bones about

Italy’s discipline...

https://edition.cnn.com/world/live-news/coronavirus-

outbreak-03-19-20-intl-hnk/h_ce08d27816652ab99a24eafa2d5cb5aa 

 

(Scroll down to the headline, “Chinese coronavirus experts warn northern Italy’s lockdown measures are not enough.”)

He says in no uncertain terms that Italy was “not strict enough,” adding..

"Here in Milan, the hardest hit area by COVID-19, there isn’t a very strict lockdown: public transportation is still working and people are still moving around, you’re still having dinners and parties in the hotels and you’re not wearing masks. We need every citizen to be involved in the fight of COVID-19 and follow this policy.”

This showcases the importance of no-compromise, putting the blame for ongoing poor performance in the face of “shutdown” into the right perspective. He also advised Italians to stop all “economic activities and cut the mobility of people. Everyone should just stay at home.”

You’re either in all the way or out. There’s no “part pregnant” status here.

That’s the takeaway for countries doing battle. The takeaway for you?

Takeaway #7

Beware the media.

Trust only those you know provide reliable information. 

There’s a lot of solid work being done. And big tech is joining forces to eliminate false info, at a level and cooperation never seen before. Get your news only from the truly credible.

There is also, unfortunately, quite a bit of poor journalism, not to mention biased reporters with an agenda (Democrat or Republican, Chinese vs America, etc.). And many (doomed to hell, I hope) remain dedicated to flooding social media with false and potentially harmful information.

So yes, be careful. Subject what you read to the model and principles laid out here. In other words, turn your BS Detector up to maximum sensitivity.

All right! We’re making good progress. 

The next 3 of The Big Six are the all-important must do’s that have to be enforced by each country — these take commitment, physically enforced if/where needed, but ideally with voluntary “us vs. virus” enthusiasm.

 

4)    Aggressive quarantines, both external and internal. 

This terminology is generally saved for those who are known to be ill with the disease, or expected to have it if testing is not available or if a test is equivocal. 

 

 

You simply can’t have this virus seeding all over the world, or back to your family. The Chinese did quarantine brilliantly, aggregating those who were ill into large areas — stadiums, warehouses, dedicated hospitals, etc. More on that elsewhere.

 

5)    Self-isolation.

Cut yourself off from the rest of the world. Stock up and hunker down. It can be voluntary or regulated.

This is generally used if your status is unknown but worrisome  (e.g., arriving from a country with widespread CV19, or close contact with same).

 

6)    Social distancing.

Stop unnecessary contact with others, including no travel. Hooray for introverts — we can avoid people to our hearts’ content. OK, back in “serious mode”...

This is generally used by well people, ideal for everyone in the country, especially if everyone does it at the same time, i.e., see the video of investor Bill Ackman’s passionate plea, referred to earlier...

https://www.cnbc.com/amp/2020/03/18/bill-ackman-pleads-to-trumpto-increase-closures-to-save-the-economy-shut-it-down-now.html

Bottom Line of the Last 3 of The Big Six...

Starve the virus by depriving it of new hosts.

Let’s repeat that for extra emphasis...

Starve the virus by depriving it of new hosts.

Simple Summary

There’s a new predator on this planet. We’re the prey. It can’t chase us, but we can’t see it. The obvious solution...

Keep yourself, friends and family out of its way.

It’s a daunting task, but it’s doable. We learn more and more about the virus every day. The entire science community is working together. It will further improve on how we manage.

The “Big Stop” is the next step. Antivirals and vaccines will stop it, but we’re many months/a year+ away. The antiviral medication will cut death rates down, not to mention the morbidity. The vaccine will eradicate it, or at least this version of it (no available hosts to infect). 

Whether that’s a forever fix, or done on an annual basis (along with a flu shot), remains to be seen. On the flip side, we remain in danger from a possible second mutation wave such as the Spanish Flu (most deaths were on its second wave).

So once again, it’s all about time.

Next…

Who Puts This All Into Place?

Government should be doing the first three and imposing and enforcing the latter three with strict commitment. There should be one, optimal program for all countries to put into place.

Instead, we see a hodge-podge of countries with many different programs, enforced to varying degrees. Ditto for the states and cities in the U.S. The only way to rigorously rid ourselves of this danger is to “franchise” the approach.

Instead, it’s simply taking too many countries too long to get there. Even programs at the national level take too long. Debates and votes in the U.S. Congress and Senate take a week, at least. I know that’s fast (relative to a snail’s pace).

But speed is of the essence. In a week, the extent of the viral spread quadruples (or octuples). We’re out of time!

I’ll cover how China rolled with this in a bit. Suffice it to say (again) that it takes draconian measures (by our free world standards) to do this. As the U.S. starts doubling its way beyond ICU bed and ventilator capacity, however, we’ll see it in more and more spots (e.g., Washington state, San Francisco, New York state). However...

All of this must not be done piecemeal, here and there by local authorities. I cringe when I hear what the city of New York is planning, or what was just done in the state of Washington. It takes a nationwide shutdown and relentless execution of The Big Six.

I’ve written this essay over a period of several days. Some has already come to pass. “Espresso,” a daily update of top stories, tellsme it’s a story of every country for itself, outlining that this country is doing this, that one doing that. Elsewhere, I read much the same about what’s going on in the U.S. 

Meanwhile, the numbers are going up, up, up, many weeks after the time when China quarantined like crazy, shutting down a huge part of the country. 

Last week’s issue of the Economist has the answer on its front page... a Closed sign over the planet. It should not mean what’s happening region by region, city by city. It must mean “Planet Closed.”

That would be ideal, but would take impossibly long, given the rising tide of contentious nationalism, a tsunami that would swamp any attempts at a world-level solution. We must accept the “possible-butstill-bloody-difficult”...

Our counterattack against SARS-CoV-2 must be started and run nationally, and now — without option for states or cities to do their own thing (aside, maybe, from legislating even more stringent “add-ons” or locale-specific supplementation). That policy must exclude access to the country implementing the total shutdown.

Uniform action across an entire nation has all the advantages of excellent franchised restaurants. Regardless of where people live, they’d get consistent quality with flawless execution of one program throughout.

That’s what wins!   Risky?

I sure hope that at one point, and soon, the government of the U.S. takes over the reins of variable local practices and institutes a nationwide plan. There simply isn’t time to lose, not anymore. But, you ask...

“Isn’t that a risky move for the government? Hey, it could be really unpopular and backfire.”

Hmmm. That was spoken like a true politician, at least today’s version of what passes for politicians. Follow (polls), don’t lead, right? Wrong...

Yup, that just may be risky politically, but it’s rock solid medically. Why do you really think politicos took (and are still taking in most cases) so long? Politics — their career — wins out over our health.

And sadly, while it’s all something that every country should be doing, it’s already too late, unless rolled out with incredibly disciplined efficiency. If the above national shutdown program were executed nationwide in the U.S. tomorrow, it would take a fierce determination and a megantic budget, including strong “us vs the virus” buy-in from the population. 

Speaking of the cost, that “megantic budget”...

It blows up, up, up when everything shuts down (there’s no GDP, basically) because the Federal Government still covers all costs, including the salaries of everyone staying at home. 

It’s doable in the short-term, where the virus is beaten, but it will deliver a major blow over a much longer period to the budget, shooting the deficit way up, while crushing the economy into a severe recession or (at the other end of the spectrum) hyperinflation.

The bad news is that this final “expense” would take the calculated value of $37.5T and push that final deficit number to over $40T! The good news is that the extra money will no longer be wasted on symptoms (stock market and economy). Instead...

Deprive the virus of hosts, and the numbers will drop in the coming months. The shutdown must then be slowly and carefully unfolded, with massive testing to watch for recurrence.

Let’s hope that the “wasted money” turns out to be the stimulation needed to jump-start the economy, which will help deal with that stratospheric debt (which is finally looked at with gravity by government).

Next, once SARS-CoV-2 is brought down to near-zero levels (China has had zero no new internal cases over the past several days, so that’s a realistic goal, yay!), the work is not done. 

It’s time now to start this generation’s “Project Manhattan,” ideally a worldwide program. Rather than fragmented labs around the globe, “Project V&V” is a joint effort of the best and brightest, with but a single goal...

Deliver the vaccine and antivirals that will bring us the rest of the way home. Meaning...

Eliminate the virus within a year with antivirals (for those who get ill, and there would still be some who do) and vaccines (for those who have yet to get it, this is the final blow against it), as well as to vaccinate against the next outbreak, much like the yearly Influenza shot, assuming it behaves similarly).

That is the ultimate global destination. But right now, total national shutdown (including sealing all borders) is a program whose time is almost past. No time to lose, we can still beat it back. 

There is no other way.

Takeaway #8

Be hard. Be strong. Be ready to make hard decisions. Do not trust communications from government. Re-read this document if need be. Its principles have already served my family well. May it do the same for yours.

 

I hope that you now have the tools you need to deal with the news and find the optimal route to safety for you and your loved ones. I used the concepts here to bring my daughter Nori to Panama, despite having accumulated a massive inventory of food and supplies in Anguilla months before this. However...

Anguilla is a small island. What happens when the supply chain breaks down? There may not be a boat for months. People do anything when that happens. There’s no strong leadership. The island was only closed after it was clear that tourism was dead, when there was nothing to lose. 

There have been no reported cases, but there have been no test kits either. This will prove to be a convenient excuse. Having talked to doctors and a pharmacist on the island, there are many people with “colds” and sicker (with a fever). It has been convenient not to be able to test.

Now that tourists are gone and not returning, the first case will be announced, then a second. The real issue, though, is that there are likely hundreds of people with the virus, infecting others over the past weeks due to a lack of any real information (except for “wash your hands” type of info). There’s no strong policy/program.

I say this only to show how you can use the concepts here to decide your own best route, regardless of what politicians say. They “work” whether you live in the most advanced, large nations of the world or the smallest island.

As I type this, Panama has just imposed a total shutdown. It’s happening. It will happen wherever you are. Please, if you have any doubts about what’s written here, end them. I know it’s hard...

We cling to normalcy bias with intensity. All I can say is…

Life is changed, almost surely forever, and in some ways for the good. But it’s the next 6 months to a year that will be most different — we all have to get through it, together. Get prepared if you have not yet done so.

A Thought Experiment in Exponential Growth

Following along with this should make you comfortable with the important concept of exponential growth. Not just what it is, but how it explains much of what we’ve seen so far...

Let’s leave Earth for “Planet Thawt,” a thought-experiment planet with

1,000,000,000 (1 billion) people (“Thawtians, I suppose ). No borders. Each person is merely 1 of 1,000,000,000 citizens. 

Along comes a virus that makes 1 of them sick. Then another.  And another. 

Let’s assume that it takes 1 week for the number of cases to double.

(I’m keeping this simple with nice, round numbers, so I’m not using Earth numbers — it’s the concepts that matter.) 

At the end of Week 2, there are 2 cases, 4 at the end of Week 3, then 8, 16, etc. at the end of each successive week.

It would, therefore, take 10 weeks after “Patient Zero” (2 and a half months) to go from 1 to 1,000 people. What does that mean to most people on Thawt? Nada. Here’s why.

That’s still “only” 1,000 people out of the 1,000,000,000 on Thawt. That’s only 1 person per million. And heck, it’s happening somewhere in Thawt that’s far, far away for most, a place called Wuhan (what a coincidence! ). 

Reaction?

“It’s never going to reach me!”

Even in Wuhan, a city with 5,000,000 people, it’s hardly noticeable. Given the time of year, it would be attributed to “a bug going around.” And then...

The hammer drops. Deaths...

No one takes notice of one person dying. Nor a second. But when a few people die, a clinician or pathologist or nurse is bound to have crossed paths with 2 or 3 patients. They ask the critical question that’s about to start a massive undertaking (not having the least inkling of that — yet)...

“Why were those deaths different?”

They notice the negative Influenza test, the appearance of the lungs on CT, etc. This is no longer “a fluke” — it’s like nothing they’ve seen before. 

Now it’s a story. It makes the local newspapers and maybe a brief article on page 12 of the “Planet Daily” about some curious disease that has killed a few people. 

But that’s about it. 

Not a big deal from a planetary perspective. Things come and go — that’s “normal.” And normalcy bias is a powerful thing.

Locals are starting to worry, though. And so are some sharp local doctors who start working together, reviewing charts of the recently deceased and being on special alert for more cases going forward.

They finally report it, once they’re sure....

“Something new is killing people. It’s going to cause more deaths.” They petition local politicians, pleading...

This is the time to contain it, while it’s still local. If we don’t, it will spread and kill millions.”

And yes indeed... That is the time to get it done!

It’s still geographically tight, and those few who have flown to other parts of the planet can still be tracked down and tested, along with their contacts (if they’re positive). It can be contained pretty easily — the earlier, the (geometrically) better.

However...

The whole story is so bizarre, so outside the norm, that the few politicians who know? They’re partly “new-reality-stunned” and partly afraid of going into action over something they can’t even see. 

I mean, put yourself into their shoes — are you willing to look like “Chicken Little?”

So “Mr. Jones” kicks it up the ladder. By the time it reaches all the way to the top “Mr. Jones,” then gets discussed, more info requested, etc., etc we’re at Week 5 — only 32 people, lots of time to decide what to do...

“Is this even real? Let’s not panic over 30 people. Form a committee.”

I’m not defending them. At this early stage, you need a champion willing to make the tough call to early action. That person would be a combination of one part super-smart, one part hero and one part visionary-moral leader — a maverick ready to tell “the system” this...

“We have a major problem, one that needs serious action now.”

That type of person does not grow on trees, let alone get into politics. What are the odds of finding an early stage champion who is in power, someone who makes the call to strong action now?

Remote.

Thawt did have two heroes who saw the future, a young doctor-andnurse team, but they got blamed for scare-mongering. All pleas are scanned-and-canned if/when they finally reach the highest levels.

Worse, as those in the upper echelons come to understand, they then decide to stifle it because their system would look weak, perhaps even blamed. We cross the line into people with evil intent.

Inertia and self-interest are strong stoppers to early action. So... inaction. You don’t have to be evil or merely lack vision to get it wrong at this point. Normalcy bias is powerful. 

But the virus doesn’t care about why, it’s just glad to have time. It loves time!

Tick.  Double.  Tock.  Double.  Tick.  Double.  Tock...

In the real (our) world, Chinese leaders suppressed its existence, denied it, even as leaks sprung. They even disciplined the young doctor who first blew the whistle (and later died of the disease, as have so many in the medical community — they are the heroes of Earth’s story). 

But the “stiflers” — that is a whole other type of wrong — unforgivable on many levels.

Let’s get back to Planet Thawt Any delay in action, whatever the motivation, is a critical loss of time. It’s amazing how inertia sets in, despite urgency. It’s now Week 10, 1,024 active cases and 12 dead.

We’re close to losing control, where containment is no longer going to eliminate this problem.

Inaction can still last for a while longer without much harm seeming to happen. In week 11, we’re at 2,000, then 4,000 in week 12 on Thawt.

Deaths are nearing 100.

The local medical community is alarmed, while the Planetary

Commission of Medicine is pressuring government at the highest levels. Worst of all (for politicians), the press is hot on the story and pumping out hard headlines.

Denials no longer work. They’re “looking into it,” while some in progovernment media belittle it with jokes...

“More people died this week from auto crashes, but you don’t get upset about that. Why don’t you worry about that this week?” 

Most Thawtians, excluding a growing minority, have a (false) sense of calm — “surely our government would not lie about that.” Most Thawtians don’t think and respond critically. So, for example, when they hear the “auto crash” answer, no one says...

“Yeah, but the number of deaths from car crashes isn’t doubling  each week.” 

Nor do people ask...

“OK, but we know what their cause of death is — do you know why these new deaths are happening? How to avoid it?“ 

The author of ThawtBlog did. But Thawt does not seem to encourage independent thought, especially if it’s critical...

She disappeared.

Hence the playbook for politicos...

When in doubt, appear relaxed and distract with noise. It has always been a “go-to” in the past, a successful way to play for time, time that no one has because, here’s the biggie...

If inaction persists, it only takes the same amount of time to go from 1,000 to 1,000,000 cases as it did to go from 1 to 1,000!!!

Think about that...

999,000 more people will get it in the same amount of time as it took for the first 1,000 people to become sick. How?

The growing number of people with the virus met, shook hands, kissed, and hugged their way through networks of friends, family, colleagues, who in turn do the same. Kids brought it home from school, with nary a symptom.

The final jump to 1,000,000 from 500,000 was just as easy as going from 512 to 1024 because the actions that spread it multiply to the same degree. 

To use a tech term, this disease scales.

And this is way more than “s/he gave it to 2, who gave it to 4, who gave it to 8, etc.), all proceeding in a nice mathematical, local progression. It’s “network-exponential,” which is incredibly hard for epidemiologists to backtrack and find sources. 

We all have networks of people we know. They break into clusters — family, friends, colleagues in a different city and random intersections. For those who have it, the virus rips through every person’s network.

It spreads locally and to faraway places (business meetings, vacations, etc.). Even the busboy — you kindly pressed a few dollars into his palm to help with university (who takes it back to the dorm).

At the end of 5 months (another 2.5 months — only 10 more doubles after the first 1,000), 1 million people have it. That’s 1/10th of 1% of

Thawt’s population. As a fraction, it doesn’t sound like much, does it? 

It’s huge

Unbeknownst to most, it’s way too late for a containment policy to work. They’re at the end of the hockey stick, only 2.5 more months until the entire planet has it (yup, that same 10 week period will add 999,000,000 (999 million) with the same ease as when it added 999).

Sustained-exponential can’t happen in real life. The straight-doubling will slow down when more people have it than don’t. You can’t pass it to someone who already has it. 

Also, even the dumbest, most corrupt government has to do something at some point, or face a mob ready to storm the gates. Martial law is a convenient way to slow the virus and the mob.

But let’s not worry about that on Thawt — it’s a Thought Experiment, so we can suspend certain laws.

Everyone on Thawt will have it after just 7.5 months.

Where were we? Oh yes, 1,000,000 have it...

There’s just no way to track down 1,000,000 cases and every contact at these levels. The problem is too big and the “sneaky-contagious” spread is too messy.

But oops... I got ahead of myself — we’re not even there yet.

We’re at 2,000 cases and a few deaths. Deaths seem to occur in about 1 of 100 cases, a week or two after symptoms start, which is a week or two after being exposed (again, I’m not trying to match the real world’s data, just establish principles to help us think this through). And it’s mostly the older people who die.

We’ve all seen the “power curve” of exponential growth. At first, the line is almost horizontal as it goes from left to right (with Time as the Xaxis and the number of sick (or dead) as the Y axis). It looks like this back on Earth...

https://www.worldometers.info/coronavirus/country/us/

(Scroll down and see all the hockey sticks — cases, deaths, new cases vs recoveries, etc. See how it’s flat at first, then starts its swing upward? That’s the hockey stick.)

Then it “hockey sticks” upwards — I’ll call that the “inflection point” but it’s not a single point. It’s the series of points that Thawt has entered, somewhere along a curve that grows increasingly vertical until it’s almost straight up (as we double from 125 million to the full Thawt population of 1 billion people).

We’re not there (yet), though. We’re early in the hockey stick (let’s say Day 12 or so).

Scientists are screaming, the media blaring... “Do something!” What the politicians do depends on when they’re ready to move past “newreality-stunned,” then past “denial” (don’t want to admit they were wrong, fear of being punished by their political boss, or whatever, and later it’s due to the top leaders’ self-interest).

There was lots of blame right here, as the alarm moved up the Chinese leadership structure. 

A combination of bad motives and the disadvantage of being “first” led to time being lost. Part of this is natural... the rest, as it got closer to the top, is evil.

But let’s stick to the story on Thawt.

Some of the Wuhandles who have the virus will soon be overwhelming local medical resources. Right now, though, they have already unwittingly started new clusters all over Wuhan, and some all over Thawt (there are great beaches in “my” Thawt, by the way — sadly, tourists bring it to those who work at every resort, too, who then go out and spread it even more).

Each of those near and far-flung clusters start with their own doubling clocks. They will be lucky because they are weeks behind Wuhan’s clock. They will be able to act fast and decisively — no risk of being wrong, with lots of good data available.  Oops, correction... they should be “lucky.”

That’s how it should work.

But on Thawt, it’s “just” going to be a loss of time, every day of which lets the disease grow exponentially, everywhere, making it harder to track down and contain in Wuhan, while it sneakily spreads all around the planet (whose initial reaction is/was “we’re OK”).

Finally, authorities do get to “action.” What works? No half-way measures, that’s for sure. An example...

Early (Pre-inflection or Very Early Into Inflection)

At this point, containment is the way to go. The virus can be eradicated.

Let’s use an Earth example to illustrate...

Taiwan twigged to it very early on. If this was Thawt, there would be, say, a hundred or so people who are sick. In the real Taiwan, it didn’t take that many. Here’s what they did...

They sent scientists to China to study it (kudos to China for permitting that). They did not have access to all the data (I take back my kudos). Still, it was easy enough to “read the room” and realize that something big was happening.

Now here’s the key...

Having recognized reality, they dealt with it. That should not be a heroic act. Taiwan gets lots of praise (and I join that). But really, once you know what you have, how hard should it be to say...

“My God, we have to save our population!”???

The countries who got it and acted fassst — it’s almost sad that we heap praise on them. It’s depressing, though — it should have been the reflex action everywhere outside of China.

You can look up the story of Taiwan for yourself — but simple and smart action, at a time when the Taiwanese people must have been wondering WTH, got it under control. 

Lots of smart action steps, big and small, won the day. 

OK, that’s about far enough. You should write your own ending on how things end on Thawt. After all, it’s your Thought Experiment.

Exponential growth of any type (from the worst pandemic to hit us ever to compounding interest) is hard for many to grasp. 

However, it’s critical to understand. It’s not hard to ask you to take good care of yourself and loved ones. Now it’s easy to understand why you must protect others, too. Every contact starts his/her own cluster of 50 people or so before showing the disease. So one final time...

“Assume you have it too” — even if you feel perfect. Don’t infect others.

China Blame?

Let’s finish the China story of SARS-CoV-2 (it’s obnoxious of Trump and his zombie followers to use the term “Chinese Flu.”)

Yes, I know that China is now trying to spread a story that it was the

U.S. that planted the virus. It’s despicable. But I heard the term “China Flu” (and variants) well before I read this. Trump always calls out others as being divisive while he is the one who starts the nonsense.

And yes, if China had acted instead of stalled when it knew, I probably would not be writing about this at all. However, it did do a 180 just in time. And that makes China an example of the far-end of containment as a plausible solution. 

It’s most countries’ fault that they did not model on that solution fast enough, and still, even as far along as today with not enough commitment. Illinois just announced (as I write this on the 20th) a lockdown — with apologies! (“I don’t come to this decision easily.”) Worse, there’s no boots-on-the-ground policy to take advantage of freezing folks in place in their homes. But let’s get back to who did it right...

If the virus in China had doubled a couple more times, the rest of the world would have been much worse off. They clamped down hard, giving us all a model to use and a lighter viral load. 

Not on purpose, I agree. But it’s up to us to use something that works. (Chinese scientists were literally begging their confreres from around the world to use what they learned.)

Bottom line...

If China had not covered up at the start, we’d all be much better off. It paid the price, so let’s model on its success — total containment is now impossible for most places, but the strategies and execution can still slow it down enough to keep our hospitals under control (or less out of control).

Finally, China’s delay was incredibly costly, both in terms of human life and its economy. It cost them the most...

It took the largest quarantine in the history of the world for China to defeat it (no cases of Chinese nationals for several days now). But they worked together and got it done, just before it would have become impossible. 

And now their economy is in tatters. It will recover, but they’ve paid enough and don’t deserve to be stigmatized.

And that’s it. 

I don’t blame China for having this in Panama or any other country. I do blame both the governments of Anguilla and Panama where I have inside knowledge of despicable behavior that will result in more people getting it, some of whom will die.

Knowing this first-hand, I assume similar unknown stories are happening everywhere, except in those handful of countries that simply understood it and fixed it. Countries that failed to act immediately? Take a look at this...

https://www.worldometers.info/coronavirus/coronavirus-cases/

Scroll down to the first graph (“Total Cases (worldwide)”). See how it breaks into 2 curves? The first is China, showing the exponential curve. The second is “Rest of World” — showing an even more pronounced curve.

That’s not China’s fault.

And finally, who are the heroes in all this?

The doctors and nurses and EMTs and other medical personnel who work 20 hours every day, at great personal loss. Here...

https://www.washingtonpost.com/health/covid-19-hits-doctorsnurses-emts-threatening-health-system/2020/03/17/

f21147e8-67aa-11ea-b313-df458622c2cc_story.html

Here’s to those fighting on the front lines.


So How Did China Do It! How Should the Rest of the World Do It?

Great question! 

Merely doing a quarantine would have doomed those in that part of Wuhan and other quarantined spots. The reason for a geographic quarantine is much more than keeping anyone from coming in (making the fix more complicated) and from leaving (which keeps the Rest of the World (ROW) from getting it).

Once you have a population stuck within a geographic boundary, you can go to work...

They had a system where you did not keep the sick at home (thereby giving it to everyone). Here’s the step by step to finding and dealing with the sick...

Your temperature was taken everywhere — bus, entering a building, taking a cab, etc. 

If you had a fever, you did not go to your doctor (and give it to him/ her). You went to a fever clinic (mothballed SARS clinics that were reopened for this). 

You got a CBC (looking for white counts), CXR, simple 2-cut CT, etc. If you had Influenza or pneumonia, with a negative test for CV19, you went home (or to the hospital if you were really sick, as usual). If you were found to have CV19...

You went to a stadium with thousands of others. You were close to others with it, you could socialize, etc. Old ladies were encouraged to do Tai Chi or to dance — great for the lungs.

Difficult triage decisions had to be made at times. Treatment was topnotch, delivered by medical pros who knew what they were doing and were totally garbed. No need to de-garb and re-garb — because everyone has the same illness.

If you got sick enough, you went to the hospital. Some old folks who got super-sick were allowed to die (they were likely to die anyway, so it made no sense to tie up limited ICU bed space when young moms could be saved). That sounds bad, and some with political agendas attacked it, but China had no choice.

Simple. Brilliant. It scales. And...

It works.

Here’s a great description of what China did, in more detail...

https://www.msnbc.com/rachel-maddow/watch/how-a-country-

serious-about-coronavirus-does-testing-and-quarantine-80595013902

Bottom line: Enforced self-isolation and social distancing within a geographic quarantine are useless unless you take advantage of reduced mobility with smart practices! I don’t know of any state or country that’s doing anything near what China did to do that.

I pray I’m wrong, that they implement aggressive management protocols. Otherwise all they end up doing is presiding over the virus rampaging through the local population.

You want more proof of how well it works early on? Think on this...

Every other area of China where it started later was stamped out with ease. Same system, just applied earlier.

Every country had the same opportunity. Only a handful took advantage...

Once the governments of Taiwan, Norway, South Korea and Italy came to understand this math, they reacted accordingly and shut everything down. And many more countries have locked down since

I first wrote this.

Italy has it in place, but is not enforcing it hard enough. The practice does not come easily to the free world. But our sensitivities to freedom must be put aside if we hope to save hundreds of thousands.

Extreme social distancing, combined with management protocols, is the only response available to stop the virus today.

The United States is not responding correctly (a hodge-podge of city and state responses, none of which are adequate for them), nor are other countries like the UK. Countries that do not bite the bullet and respond well now will pay a much larger, catastrophic price later.

The U.S. is on the exact same curve as Italy! Time to get it done, now or never!

What’s the Deal About Herd Immunity?

Prime Minister Boris Johnson in the UK took a lot of heat for his “herd immunity” pitch. Whether it’s appropriate or not depends on his data and assumptions and where the UK government felt they are along that exponential curve (“inflection point”). Herd immunity has a long and accepted history...

https://en.wikipedia.org/wiki/Herd_immunity

It’s the foundation of vaccination. You don’t have to vaccinate everyone to get its benefits, just most. That leaves so few to get the disease that it has nowhere to turn even if it manages to fluke-find someone who has not been vaccinated.

That said, letting everyone get immune by getting the full, active disease at that time, without knowing all that we need to know about the virus, without sharing data and assumptions with rigorous transparency, was irresponsibility at its worst. It shows that Boris, too, could not care less about the people.

Don’t get me wrong...

At some point, you may get “herd immunity” whether you like it or not. A “controlled burn” (one where the weak are protected by the strong majority) is better than a rampant, uncontrolled forest fire. And many countries are approaching that stage — they’ll use the same draconian policies if they hope to do more than just let the disease roar through each country.

Even if Boris felt that they were too far along (they were not), he had a duty to protect the vulnerable, and to release data and assumptions for his conclusion. 

But frankly, if he simply closed the country down and instituted the Chinese process early on, there’d be no need to sacrifice 1% of all the healthy people in the UK.

I posted this on March 12 to the SBIer community...

The US already has more than 4 times this number of known infected cases as Wuhan did when it was shut down, and our citizens are far more mobile and therefore spreading the virus more broadly when compared to Wuhan. Yet our response is tepid at best.

It’s the 20th at the time of writing this part of this document. That means roughly 3 doublings since the 12th. The U.S. now has 32 times the number of Wuhan! 

It’s over — now they must simply try to keep the numbers as low as possible. Put the proven protocol into place!

Like Trump, Boris showed a dramatic inability to think and come to the right conclusions, along with a terrifying callousness...

They’re both out of their depth.

Reliable Updates

The John Hopkins Center for Health Security

http://www.centerforhealthsecurity.org/resources/COVID-19/

Worldometer

https://www.worldometers.info/coronavirus/country/us/ https://www.worldometers.info/coronavirus/#countries

Any reputable media that has no political agenda will also do.

The Worldometer lets you track any country. As of this writing, here’s what you’ll see...

We’re entering the scariest part of this journey. Most of the west is somewhere along the very tricky inflection part of the exponential curve. Europe is farther along than North America. 

This is where the numbers really grow (in absolute numbers). So it’s where the media gets even louder. Hopefully, once you know this, you can avoid reading all the nonsense. 

No panic. If you have a strong cache of food and supplies, if you don’t go out unless absolutely necessary, you should be fine. Protect the vulnerable in your family (that may mean you — if so, don’t be shy to explain that to your loved ones).

In most cases, it’s almost surely too late for containment to eradicate (as China has done — several days of zero new cases — China has had new cases, but they’re all from people visiting China for some reason). That does not mean that they should let herd immunity be the answer.

If all they do is close their country or state or city (meaning no one in or out), they turn their country into a killing field, that’s all. They must turn to the totally draconian and uniform policy of China, across all of Europe and North America.

And put the Chinese program into place. We’re getting closer to that, as we see more states in the U.S. getting partway there, Italy trying (but blasted by a Chinese observer that they’re still too soft).

It’s going to be a long and hard battle, because all of the large western countries are much further along than China was when they locked down and put the system into place.

As a result, the worst countries will end up with some amount of herd immunity. But that is a very small consolation prize, especially since vaccines and antivirals are in the works. 

The bottom line is: do what we know works, until Project V&V yields results and turns SARS-CoV-2 into just another virus for which we’ll need a vaccine, possibly annually with our flu shot.

Be careful, folks. It’s dangerous out there. Your safety is in your hands and no one else’s.

In case you’re wondering about the Bob Dylan reference...

https://en.wikipedia.org/wiki/Ballad_of_a_Thin_Man#Meaning


The scientific advances we need to stop COVID-19

By Bill Gates

|

April 23, 2020 24 minute read

520

The coronavirus pandemic pits all of humanity against the virus. The damage to health, wealth, and well-being has already been enormous. This is like a world war, except in this case, we’re all on the same side. Everyone can work together to learn about the disease and develop tools to fight it. I see global innovation as the key to limiting the damage. This includes innovations in testing, treatments, vaccines, and policies to limit the spread while minimizing the damage to economies and well-being.

This memo shares my view of the situation and how we can accelerate these innovations. (Because this post is long, it is also available as a PDF.) The situation changes every day, there is a lot of information available—much of it contradictory—and it can be hard to make sense of all the proposals and ideas you may hear about. It can also sound like we have all the scientific advances needed to re-open the economy, but in fact we do not. Although some of what’s below gets fairly technical, I hope it helps people make sense of what is happening, understand the innovations we still need, and make informed decisions about dealing with the pandemic.

Exponential growth and decline

In the first phase of the pandemic, we saw an exponential spread in a number of countries, starting with China and then throughout Asia, Europe, and the United States. The number of infections was doubling many times every month. If people’s behavior had not changed, then most of the population would have been infected. By changing behavior, many countries have gotten the infection rate to plateau and start to come down.

Exponential growth is not intuitive. If you say that 2 percent of the population is infected and this will double every eight days, most people won’t immediately figure out that in 40 days, the majority of the population will be infected. The big benefit of the behavior change is to reduce the infection rate dramatically so that, instead of doubling every eight days, it goes down every eight days.

We use something called the reproduction rate, or R0 (pronounced “are-nought”), to calculate how many new infections are caused by an earlier infection. R0 is hard to measure, but we know it’s below 1.0 wherever the number of cases is going down and above 1.0 wherever the number of cases is going up. And what may appear to be a small difference in R0 can lead to very large changes.

If every infection goes from causing 2.0 cases to only causing 0.7 infections, then after 40 days you have one-sixth as many infections instead of 32 times as many. That’s 192 times fewer cases. Here’s another way to think about it: If you started with 100 infections in a community, after 40 days you would end up with 17 infections at the lower R0 and 3,200 at the higher one. Experts are debating now just how long to keep R0 very low to drive down the number of cases before opening up begins.

Exponential decline is even less intuitive. A lot of people will be stunned that in many places we will go from hospitals being overloaded in April to having lots of empty beds in July. The whiplash will be confusing, but it is inevitable from the exponential nature of infection.

As we get into the summer, some locations that maintain behavior change will experience exponential decline. However, as behavior goes back to normal, some locations will stutter along with persistent clusters of infections and some will go back into exponential growth. The picture will be more complex than it is today, with a lot of heterogeneity.

Have we overreacted?

It is reasonable for people to ask whether the behavior change was necessary. Overwhelmingly, the answer is yes. There might be a few areas where the number of cases would never have gotten large numbers of infections and deaths, but there was no way to know in advance which areas those would be. The change allowed us to avoid many millions of deaths and extreme overload of the hospitals, which would also have increased deaths from other causes.

The economic cost that has been paid to reduce the infection rate is unprecedented. The drop in employment is faster than anything we have ever experienced. Entire sectors of the economy are shut down. It is important to realize that this is not just the result of government policies restricting activities. When people hear that an infectious disease is spreading widely, they change their behavior. There was never a choice to have the strong economy of 2019 in 2020.

Most people would have chosen not to go to work or restaurants or take trips, to avoid getting infected or infecting older people in their household. The government requirements made sure that enough people changed their behavior to get the reproduction rate below 1.0, which is necessary to then have the opportunity to resume some activities.

The wealthier countries are seeing reduced infections and starting to think about how to open up. Even as a government relaxes restrictions on behavior, not everyone will immediately resume the activities that are allowed. It will take a lot of good communication so that people understand what the risks are and feel comfortable going back to work or school. This will be a gradual process, with some people immediately doing everything that is allowed and others taking it more slowly. Some employers will take a number of months before they require workers to come back. Some people will want the restrictions lifted more rapidly and may choose to break the rules, which will put everyone at risk. Leaders should encourage compliance.

Differences among countries

The pandemic has not affected all countries equally. China was where the first infection took place. They were able to use stringent isolation and extensive testing to stop most of the spread. The wealthier countries, which have more people coming in from all over the world, were the next to be affected. The countries that reacted quickly to do lots of testing and isolation avoided large-scale infection. The benefits of early action also meant that these countries didn’t have to shut down their economies as much as others.

The ability to do testing well explains a lot of the variation. It is impossible to defeat an enemy we cannot see. So testing is critical to getting the disease under control and beginning to re-open the economy.

So far, developing countries like India and Nigeria account for a small portion of the reported global infections. One of the priorities for our foundation has been to help ramp up the testing in these countries so they know their situation. With luck, some factors that we don’t understand yet, like how weather might affect the virus’s spread, will prevent large-scale infection in these countries.

However, our assumption should be that the disease dynamics are the same as in other countries. Even though their populations are disproportionately young—which would tend to mean fewer deaths from COVID-19—this advantage is almost certainly offset by the fact that many low-income people’s immune systems are weakened by conditions like malnutrition or HIV. And the less developed a country’s economy is, the harder it is to make the behavior changes that reduce the the virus's reproduction rate. If you live in an urban slum and do informal work to earn enough to feed your family every day, you won’t find it easy to avoid contact with other people. Also, the health systems in these countries have far less capacity, so even providing oxygen treatment to everyone who needs it will be difficult.

Tragically, it is possible that the total deaths in developing countries will be far higher than in developed countries.

What we need to learn

Our knowledge of the disease will help us with tools and policies. There are a number of key things we still don’t understand.  A number of studies are being done to answer these questions, including one in Seattle done with the University of Washington. The global collaboration on these issues is impressive and we should know a lot more by the summer.

Is the disease seasonal or weather dependent? Almost all respiratory viruses (a group that includes COVID-19) are seasonal. This would mean there are fewer infections in the summer, which might lull us into complacency when the fall comes. This is a matter of degree. Because we see the novel coronavirus spreading in Australia and other places in the Southern hemisphere, where the seasons are the opposite of ours, we already know the virus is not as seasonal as influenza is.

How many people who never get symptoms have enough of the virus to infect others? What about people who are recovered and have some residual virus—how infectious are they? Computer models show that if there are a lot of people who are asymptomatic but infectious, it is much harder to open up without a resurgence in cases. There is a lot of disagreement about how much infection comes from these sources, but we do know that many people with the virus don’t report symptoms, and some portion of those might end up transmitting it.

Why do young people have a lower risk of becoming seriously ill when they get infected? Understanding the dynamics here will help us weigh the risks of opening schools. It is a complicated subject because even if young people don’t get sick as often, they might still spread the disease to others.

What symptoms indicate you should get tested? Some countries are taking the temperature of lots of people as an initial screening tool. If doing this helps us find more potential cases, we could use it at airports and large gatherings. We need to target the tests we have at the people at greatest risk since we don’t have enough tests for everyone.

Which activities cause the most risk of infection? People ask me questions about avoiding prepared food or door knobs or public toilets so they can minimize their risk. I wish I knew what to tell them. Judgements will have to be made about different kinds of gatherings like classes or church going and whether some kind of spacing should be required. In places without good sanitation, there may be spread from fecal contamination since people who are infected shed the virus.

Who is most susceptible to the disease? We know that older people are at much greater risk of both severe illness and death. Understanding how gender, race, and co-morbidities affect this is a work in progress.

The Gates Foundation’s role

In normal times, the Gates Foundation puts more than half of its resources into reducing deaths from infectious diseases. These diseases are the reason why a child in a poor country is 20 times more likely to die before the age of five than one in a rich country. We invest in inventing new treatments and vaccines for these diseases and making sure they get delivered to everyone who needs them. The diseases include HIV, malaria, tuberculosis, polio, and pneumonia. Whenever there is an epidemic like Ebola, SARS, or Zika we work with governments and the private sector to help model the risks and to help galvanize resources to create new tools to stop the epidemic. It was because of these experiences that I spoke out about the world not being ready for a respiratory epidemic in my 2015 TED talk. Although not enough was done, a few steps were taken to prepare, including the creation of the Coalition for Epidemic Preparedness Innovation, which I will discuss below, in the vaccine section.

Now that the epidemic has hit, we are applying our expertise to finding the best ideas in each area and making sure they move ahead at full speed. There are many efforts going on. More than 100 groups are doing work on treatments and another 100 on vaccines. We are funding a subset of these but tracking all of them closely. It is key to look at each project to see not only its chance of working but also the odds that it can be scaled up to help the entire world.

One urgent activity is to raise money for developing new tools. I think of this as the billions we need to spend so we can save trillions. Every additional month that it takes to get the vaccine is a month when the economy cannot return to normal. However, it isn’t clear how countries will come together to coordinate the funding. Some could go directly to the private sector but demand that their citizens get priority. There is a lot of discussion among governments, the World Health Organization, the private sector, and our foundation about how to organize these efforts.

Innovation to beat the enemy

During World War II, an amazing amount of innovation, including radar, reliable torpedoes, and code-breaking, helped end the war faster. This will be the same with the pandemic. I break the innovation into five categories: treatments, vaccines, testing, contact tracing, and policies for opening up.Without some advances in each of these areas, we cannot return to the business as usual or stop the virus. Below, I go through each area in some detail.

Treatments

Every week, you will be reading about new treatment ideas that are being tried out, but most of them will fail. Still, I am optimistic that some of these treatments will meaningfully reduce the disease burden. Some will be easier to deliver in rich countries than developing countries, and some will take time to scale. A number of these could be available by the summer or fall.

If in the spring of 2021 people are going to big public events—like a game or concert in a stadium—it will be because we have a miraculous treatment that made people feel confident about going out again. It’s hard to know precisely what the threshold is, but I suspect it is something like 95 percent; that is, we need a treatment that is 95 percent effective in order for people to feel safe in big public gatherings. Although it is possible that a combination of treatments will have over 95 percent effectiveness, it’s not likely, so we can’t count on it. If our best treatments reduce the deaths by less than 95 percent, then we will still need a vaccine before we can go back to normal.

One potential treatment that doesn’t fit the normal definition of a drug involves collecting blood from patients who have recovered from COVID-19, making sure it’s free of the coronavirus and other infections, and giving the plasma to people who are sick. The leading companies in this area are working together to get a standard protocol to see if this works. They will have to measure each patient to see how strong their antibodies are. A variant of this approach is to take the plasma and concentrate it into a compound called hyperimmune globulin, which is much easier and faster to give a patient than unconcentrated plasma. The foundation is supporting a consortium of most of the leading companies that work in this area to accelerate the evaluation and, if the procedure works, be ready to scale it up. These companies have developed a Plasma Bot to help recovered COVID-19 patients donate plasma for this effort.

Another type of potential treatment involves identifying the antibodies produced by the human immune system that are most effective against the novel coronavirus. Once those antibodies have been found, they can be manufactured and used as a treatment or as a way to prevent the disease (in which case it is known as passive immunization). This antibody approach also has a good chance of working, although it’s unclear how many doses can be made. It depends on how much antibody material is needed per dose; in 2021, manufacturers may be able to make as few as 100,000 treatments or many millions. The lead times for manufacturing are about seven months in the best case. Our grantees are working to compare the different antibodies and make sure the best ones get access to the limited manufacturing capacity.

There is a class of drugs called antivirals, which keep the virus from functioning or reproducing. The drug industry has created amazing antivirals to help people with HIV, although it took decades to build up the large library of very effective triple drug therapies. For the novel coronavirus, the leading drug candidate in this category is Remdesivir from Gilead, which is in trials now. It was created for Ebola. If it proves to have benefits, then the manufacturing will have to be scaled up dramatically.

The foundation recently asked drug companies to provide access to their pipeline of developed antiviral drugs so researchers funded by the Therapeutics Accelerator can run a screen to see which should go into human trials first. The drug companies all responded very quickly, so there is a long list of antivirals being screened.

Another class of drugs works by changing how the human body reacts to the virus. Hydroxychloroquine is in this group. The foundation is funding a trial that will give an indication of whether it works on COVID-19 by the end of May. It appears the benefits will be modest at best. Another type of drug that changes the way a human reacts to a virus is called an immune system modulator. These drugs would be most helpful for late-stage serious disease. All of the companies that work in this area are doing everything they can to help with trials.

Vaccines

Vaccines have saved more lives than any other tool in history. Smallpox, which used to kill millions of people every year, was eradicated with a vaccine. New vaccines have played a key role in reducing childhood deaths from 10 million per year in 2000 to fewer than 5 million per year today.

Short of a miracle treatment, which we can't count on, the only way to return the world to where it was before COVID-19 showed up is a highly effective vaccine that prevents the disease.

Unfortunately, the typical development time for a vaccine against a new disease is over five years. This is broken down into:  a) making the candidate vaccine; b) testing it in animals; c) safety testing in small numbers of people (this is known as phase 1);  d) safety and efficacy testing in medium numbers (phase 2); e) safety and efficacy testing in large numbers (phase 3); and f) final regulatory approval and building manufacturing while registering the vaccine in every country.

Researchers can save time by compressing the clinical safety/efficacy phases while conducting animal tests and building manufacturing capacity in parallel. Even so, no one knows in advance which vaccine approach will work, so a number of them need to be funded so they can advance at full speed. Many of the vaccine approaches will fail because they won’t generate a strong enough immune response to provide protection. Scientists will get a sense of this within three months of testing a given vaccine in humans by looking at the antibody generation. Of particular interest is whether the vaccine will protect older people, whose immune systems don’t respond as well to vaccines.

The issue of safety is obviously very important. Regulators are very stringent about safety, to avoid side effects and also to protect the reputation of vaccines broadly, since if one has significant problems, people will become more hesitant to take any vaccines. Regulators worldwide will have to work together to decide how large the safety database needs to be to approve a COVID-19 vaccine.

One step that was taken after the foundation and others called for investments in pandemic preparedness in 2015 was the creation of the Coalition for Epidemic Preparedness Innovations (CEPI). Although the resources were quite modest, they have helped advance new approaches to making vaccines that could be used for this pandemic. CEPI added resources to work on an approach called RNA vaccines, which our foundation had been supporting for some time. Three companies are pursuing this approach. The first vaccine to start human trials is an RNA vaccine from Moderna, which started a phase 1 clinical safety evaluation in March.

An RNA vaccine is significantly different from a conventional vaccine. A flu shot, for example, contains bits of the flu virus that your body’s immune system learns to attack. This is what gives you immunity. With an RNA vaccine, rather than injecting fragments of the virus, you give the body the genetic code needed to produce lots of copies of these fragments. When the immune system sees the viral fragments, it learns how to attack them. An RNA vaccine essentially turns your body into its own vaccine manufacturing unit.

There are also at least five leading efforts that look promising and that use other approaches to teach the immune system to recognize and attack a viral infection. CEPI and our foundation will be tracking efforts from all over the world to make sure the most promising ones get resources. Once a vaccine is ready, our partner GAVI will make sure it is available even in low-income countries.

A big challenge for vaccine trials is that the time required for the trials depends on finding trial locations where the rate of infection is fairly high. While you are setting up the trial site and getting regulatory approval, the infection rate in that location could go down. And trials have to involve a surprisingly large number of people. For example, suppose the expected rate of infection is 1 percent per year and you want to run a trial where you would expect 50 people to be infected without the vaccine. To get a result in six months the trial would need 10,000 people in it.

The goal is to pick the one or two best vaccine constructs and vaccinate the entire world—that’s 7 billion doses if it is a single-dose vaccine, and 14 billion if it is a two-dose vaccine. The world will be in a rush to get them, so the scale of the manufacturing will be unprecedented and will probably have to involve multiple companies.

I am often asked when large-scale vaccination will start. Like American’s top public health officials, I say that it is likely to be 18 months, even though it could be as short as nine months or closer to two years. A key piece will be the length of the phase 3 trial, which is where the full safety and efficacy are determined.

When the vaccine is first being manufactured, there will be a question of who should be vaccinated first. Ideally, there would be global agreement about who should get the vaccine first, but given how many competing interests there are, this is unlikely to happen. The governments that provide the funding, the countries where the trials are run, and the places where the pandemic is the worst will all make a case that they should get priority.

Testing

All of the tests to date for the novel coronavirus involve taking a nasal swab and processing it in a Polymerase Chain Reaction (PCR) machine. Our foundation invested in research showing that having patients do the swab themselves, at the tip of the nose, is as accurate as having a doctor push the swab further down to the back of your throat. Our grantees are also working to design swabs that are cheap and able to be manufactured at large scale but work as well as ones that are in short supply. This self-swab approach is faster, protects health care workers from the risk of exposure, and should let regulators approve swabbing in virtually any location instead of only at a medical center. The PCR test is quite sensitive—it will generally show whether you have the virus even before you have symptoms or are infecting other people.

There has been a lot of focus on the number of tests being performed in each country. Some, like South Korea, did a great job of ramping up the testing capacity. But the number of tests alone doesn’t show whether they are being used effectively. You also have to make sure you are prioritizing the testing on the right people. For example, health care workers should be able to get an immediate indication of whether they are infected so they know whether to keep working. People without symptoms should not be tested until we have enough tests for everyone with symptoms. Additionally, the results from the test should come back in less than 24 hours so you quickly know whether to continue isolating yourself and quarantining the people who live with you. In the United States, it was taking over seven days in some locations to get test results, which reduces their value dramatically. This kind of delay is unacceptable.

There are two types of PCR machines: high-volume batch processing machines and low-volume machines. Both have a role to play. The high-volume machines provide most of the capacity. The low volume machines are better when getting a result in less than an hour is beneficial. Everyone who makes these machines, and some new entrants, are making as many machines as they can. Adding this capacity and making full use of the machines that are already available will increase the testing capacity. The foundation is talking to the manufacturers about different ways to run the big machines that could make them more than twice as productive.

Another type of test being developed is called a Rapid Diagnostic Test (RDT). This would be like an in-home pregnancy test. You would swab your nose the same way as for the PCR test, but instead of sending it into a processing center, you would put it in a liquid container and then pour that liquid onto a strip of paper that would change color if it detects the virus. This form of test may be available in a few months. Even though it won’t be as sensitive as a PCR test, for someone who has symptoms it should be quite accurate. You would still need to report your test result to your government since they need visibility into the disease trends.

A lot of people talk about the serology test, where you give blood and it detects whether you have antibodies against the virus. If you do, it means you have been exposed. These tests only show positive results late in your disease, so they do not help you decide whether to quarantine. Also, all the tests done so far have problems with false positives. Until we understand what level of antibodies is protective and have a test with almost no false positives, it is a mistake to tell people not to worry about their exposure to infection based on the serology tests that are available today. In the meantime, serology tests will be used to see who can donate blood and to understand the disease dynamics.

A lot of countries did a good job focusing the PCR capacity on the priority patients. Most countries had their government play a central role in this process. In the United States, there is no system for making sure the testing is allocated rationally. Some states have stepped in, but even in the best states, the access isn’t fully controlled.

Testing becomes extremely important as a country considers opening up. You want to have so much testing going on that you see hot spots and are able to intervene by changing policy before the numbers get large. You don’t want to wait until the hospitals start to fill up and the number of deaths goes up.

Basically, there are two critical cases: anyone who is symptomatic, and anyone who has been in contact with someone who tested positive. Ideally both groups would be sent a test they can do at home without going into a medical center. Tests would still be available in medical centers, but the simplest is to have the majority done at home. To make this work, a government would have to have a website that you go to and enter your circumstances, including your symptoms. You would get a priority ranking, and all of the test providers would be required to make sure they are providing quick results to the highest priority levels. Depending on how accurately symptoms predict infections, how many people test positive, and how many contacts a person typically has, you can figure out how much capacity is needed to handle these critical cases. For now, most countries will use all of their testing capacity for these cases.

There will be a temptation for companies to buy testing machines for their employees or customers. A hotel or cruise ship operator would like to be able to test everyone even if they don’t have symptoms. They will want to get PCR machines that give quick results or the rapid diagnostic test. These companies will be able to bid very high prices—well above what the public health system would bid—so governments will have to determine when there is enough capacity to allow this.

One assumption is that people who need to get tested will isolate themselves and quarantine those in their household. Some governments police this carefully, whereas others simply assume people will follow the recommendation. Another issue is whether a government provides a place for someone to isolate themselves if they can’t do it at their home. This is particularly important if you have older people in close quarters at your house.

Contact tracing

I mentioned in the testing section that one of the key priorities for testing is anyone who has been in close contact with someone who has tested positive. If you can get a list of these people quickly and make sure they are prioritized for a test like the PCR test (which is sensitive enough to detect a recent infection), then these people can isolate themselves before they infect other people. This is the ideal way of stopping the spread of the virus.

Some countries, including China and South Korea, required patients to turn over information about where they have been in the last 14 days by looking at GPS information on their phone or their spending records. It is unlikely that Western countries will require this. There are applications you can download that will help you remember where you have been; if you ever test positive, then you can voluntarily review the history or choose to share it with whoever interviews you about your contacts.

A number of digital approaches are being proposed where phones detect what other phones are near them. (It would involve using Bluetooth plus sending a sound out that humans can’t hear but that verifies that the two phones are reasonably close to each other.) The idea is that if someone tests positive then their phone can send a message to the other phones and their owners can get tested. If most people voluntarily installed this kind of application, it would probably help some. One limitation is that you don’t necessarily have to be in the same place at the same time to infect someone—you can leave the virus behind on a surface. This system would miss this kind of transmission.

I think most countries will use the approach that Germany is using, which requires interviewing everyone who tests positive and using a database to make sure there is follow-up with all the contacts. The pattern of infections is studied to see where the risk is highest and policy might need to change.

In Germany, if someone is tested and confirmed positive, the doctor is legally required to inform the local government health office. The doctor must provide all personal data—name, address, phone number—so that the health office can contact the person and ensure they isolate themselves. 

Then the local health office begins the process of contact tracing. They interview the infected person, find out how to contact all the people he or she has met in the past couple of weeks, and contact those people to ask them to self-isolate and get a test.

This approach relies on the infected person to report their contacts accurately, and also depends on the ability of the health authorities to follow up with everyone. The normal health service staff can’t possibly do all this work even if the case numbers are fairly low. Every health system will have to figure out how to staff up so that this work is done in a timely fashion. Everyone who does the work would have to be properly trained and required to keep all the information private. Researchers would be asked to study the database to find patterns of infection, again with privacy safeguards in place.

Opening up

Most developed countries will be moving into the second phase of the epidemic in the next two months. In one sense, it is easy to describe this next phase. It is semi-normal. People can go out, but not as often, and not to crowded places. Picture restaurants that only seat people at every other table, and airplanes where every middle seat is empty. Schools are open, but you can’t fill a stadium with 70,000 people. People are working some and spending some of their earnings, but not as much as they were before the pandemic. In short, times are abnormal but not as abnormal as during the first phase.

The rules about what is allowed should change gradually so that we can see if the contact level is starting to increase the number of infections. Countries will be able to learn from other countries that have strong testing systems in place to inform them when problems come up.

One example of gradual reopening is Microsoft China, which has roughly 6,200 employees. So far about half are now coming in to work. They are continuing to provide support to employees who want to work at home. They insist people with symptoms stay home. They require masks and provide hand sanitizer and do more intensive cleaning. Even at work, they apply distancing rules and only allow travel for exceptional reasons. China has been conservative about opening up and has so far avoided any significant rebound.

The basic principle should be to allow activities that have a large benefit to the economy or human welfare but pose a small risk of infection. But as you dig into the details and look across the economy, the picture quickly gets complicated. It is not as simple as saying “you can do X, but not Y.” The modern economy is far too complex and interconnected for that.

For example, restaurants can keep diners six feet apart, but will they have a working supply chain for their ingredients? Will they be profitable with this reduced capacity? The manufacturing industry will need to change factories to keep workers farther apart. Most factories will be able to adapt to new rules without a large productivity loss. But how do the people employed in these restaurants and factories get to work? Are they taking a bus or train? What about the suppliers who provide and ship parts to the factory? And when should companies start insisting their employees show up at work?

There are no easy answers to these questions. Ultimately, leaders at the national, state, and local levels will need to make trade-offs based on the risks and benefits of opening various parts of the economy. In the United States it will be tricky if one state opens up too fast and starts to see lots of infections. Should other states try to stop people moving across state boundaries?

Schools offer a big benefit and should be a priority. Large sporting and entertainment events probably will not make the cut for a long time; the economic benefit of the live audience doesn’t measure up to the risk of spreading the infection. Other activities fall into a gray area, such as church services or a high school soccer game with a few dozen people on the sidelines.

There is one other factor that is hard to account for: human nature. Some people will be naturally reluctant to go out even once the government says it is okay. Others will take the opposite view—they will assume that the government is being overly cautious and start bucking the rules. Leaders will need to think carefully about how to strike the right balance here.

Conclusion

Melinda and I grew up learning that World War II was the defining moment of our parents’ generation. In a similar way, the COVID-19 pandemic—the first modern pandemic—will define this era. No one who lives through Pandemic I will ever forget it. And it is impossible to overstate the pain that people are feeling now and will continue to feel for years to come.

The heavy cost of the pandemic for lower-paid and poor people is a special concern for Melinda and me. The disease is disproportionately hurting poorer communities and racial minorities. Likewise, the economic impact of the shutdown is hitting low-income, minority workers the hardest. Policymakers will need to make sure that, as the country opens up, the recovery doesn’t make inequality even worse than it already is.

At the same time, we are impressed with how the world is coming together to fight this fight. Every day, we talk to scientists at universities and small companies, CEOs of pharmaceutical companies, or heads of government to make sure that the new tools I’ve discussed become available as soon as possible. And there are so many heroes to admire right now, including the health workers on the front line. When the world eventually declares Pandemic I over, we will have all of them to thank for it.

Read this next

NEXT

What our leaders can do now

These decisions will affect the course of COVID-19.

 

31 questions and answers about COVID-19

My thoughts on what to do now and other topics.

 

The next epidemic is coming. Here’s how we can make sure we’re ready.

I was honored to be asked to give this year’s Shattuck Lecture.

 


The vaccine race, explained

What you need to know about the COVID-19 vaccine

Humankind has never had a more urgent task than creating broad immunity for coronavirus.

By Bill Gates

|

April 30, 2020 10 minute read

760

One of the questions I get asked the most these days is when the world will be able to go back to the way things were in December before the coronavirus pandemic. My answer is always the same: when we have an almost perfect drug to treat COVID-19, or when almost every person on the planet has been vaccinated against coronavirus.

The former is unlikely to happen anytime soon. We’d need a miracle treatment that was at least 95 percent effective to stop the outbreak. Most of the drug candidates right now are nowhere near that powerful. They could save a lot of lives, but they aren’t enough to get us back to normal.

Which leaves us with a vaccine.

Humankind has never had a more urgent task than creating broad immunity for coronavirus. Realistically, if we’re going to return to normal, we need to develop a safe, effective vaccine. We need to make billions of doses, we need to get them out to every part of the world, and we need all of this to happen as quickly as possible.

That sounds daunting, because it is. Our foundation is the biggest funder of vaccines in the world, and this effort dwarfs anything we’ve ever worked on before. It’s going to require a global cooperative effort like the world has never seen. But I know it’ll get done. There’s simply no alternative.

Here’s what you need to know about the race to create a COVID-19 vaccine.

The world is creating this vaccine on a historically fast timeline.

Dr. Anthony Fauci has said he thinks it’ll take around eighteen months to develop a coronavirus vaccine. I agree with him, though it could be as little as 9 months or as long as two years.

Although eighteen months might sound like a long time, this would be the fastest scientists have created a new vaccine. Development usually takes around five years. Once you pick a disease to target, you have to create the vaccine and test it on animals. Then you begin testing for safety and efficacy in humans.

Safety and efficacy are the two most important goals for every vaccine. Safety is exactly what it sounds like: is the vaccine safe to give to people? Some minor side effects (like a mild fever or injection site pain) can be acceptable, but you don’t want to inoculate people with something that makes them sick.

Efficacy measures how well the vaccine protects you from getting sick. Although you’d ideally want a vaccine to have 100 percent efficacy, many don’t. For example, this year’s flu vaccine is around 45 percent effective.

To test for safety and efficacy, every vaccine goes through three phases of trials:

Phase one is the safety trial. A small group of healthy volunteers gets the vaccine candidate. You try out different dosages to create the strongest immune response at the lowest effective dose without serious side effects.

Once you’ve settled on a formula, you move onto phase two, which tells you how well the vaccine works in the people who are intended to get it. This time, hundreds of people get the vaccine. This cohort should include people of different ages and health statuses.

Then, in phase three, you give it to thousands of people. This is usually the longest phase, because it occurs in what’s called “natural disease conditions.” You introduce it to a large group of people who are likely already at the risk of infection by the target pathogen, and then wait and see if the vaccine reduces how many people get sick.

After the vaccine passes all three trial phases, you start building the factories to manufacture it, and it gets submitted to the WHO and various government agencies for approval.

This process works well for most vaccines, but the normal development timeline isn’t good enough right now. Every day we can cut from this process will make a huge difference to the world in terms of saving lives and reducing trillions of dollars in economic damage.

So, to speed up the process, vaccine developers are compressing the timeline.

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Global Vaccination Coverage Is at Its Highest

In the traditional process, the steps are sequential to address key questions and unknowns. This can help mitigate financial risk, since creating a new vaccine is expensive. Many candidates fail, which is why companies wait to invest in the next step until they know the previous step was successful.

For COVID-19, financing development is not an issue. Governments and other organizations (including our foundation and an amazing alliance called the Coalition for Epidemic Preparedness Innovations) have made it clear they will support whatever it takes to find a vaccine. So, scientists are able to save time by doing several of the development steps at once. For example, the private sector, governments, and our foundation are going to start identifying facilities to manufacture different potential vaccines. If some of those facilities end up going unused, that’s okay. It’s a small price to pay for getting ahead on production.

Fortunately, compressing the trial timeline isn’t the only way to take a process that usually takes five years and get it done in 18 months. Another way we’re going to do that is by testing lots of different approaches at the same time.

There are dozens of candidates in the pipeline.

As of April 9, there are 115 different COVID-19 vaccine candidates in the development pipeline. I think that eight to ten of those look particularly promising. (Our foundation is going to keep an eye on all the others to see if we missed any that have some positive characteristics, though.)

 

The most promising candidates take a variety of approaches to protecting the body against COVID-19. To understand what exactly that means, it’s helpful to remember how the human immune system works.

When a disease pathogen gets into your system, your immune system responds by producing antibodies. These antibodies attach themselves to substances called antigens on the surface of the microbe, which sends a signal to your body to attack. Your immune system keeps a record of every microbe it has ever defeated, so that it can quickly recognize and destroy invaders before they make you ill.

Vaccines circumvent this whole process by teaching your body how to defeat a pathogen without ever getting sick. The two most common types—and the ones you’re probably most familiar with—are inactivated and live vaccines. Inactivated vaccines contain pathogens that have been killed. Live vaccines, on the other hand, are made of living pathogens that have been weakened (or “attenuated”). They’re highly effective but more prone to side effects than their inactivated counterparts.

Inactivated and live vaccines are what we consider “traditional” approaches. There are a number of COVID-19 vaccine candidates of both types, and for good reason: they’re well-established. We know how to test and manufacture them.

The downside is that they’re time-consuming to make. There’s a ton of material in each dose of a vaccine. Most of that material is biological, which means you have to grow it. That takes time, unfortunately.

That’s why I’m particularly excited by two new approaches that some of the candidates are taking: RNA and DNA vaccines. If one of these new approaches pans out, we’ll likely be able to get vaccines out to the whole world much faster. (For the sake of simplicity, I’m only going to explain RNA vaccines. DNA vaccines are similar, just with a different type of genetic material and method of administration.)

Our foundation—both through our own funding and through CEPI—has been supporting the development of an RNA vaccine platform for nearly a decade. We were planning to use it to make vaccines for diseases that affect the poor like malaria, but now it’s looking like one of the most promising options for COVID. The first candidate to start human trials was an RNA vaccine created by a company called Moderna.

Here’s how an RNA vaccine works: rather than injecting a pathogen’s antigen into your body, you instead give the body the genetic code needed to produce that antigen itself. When the antigens appear on the outside of your cells, your immune system attacks them—and learns how to defeat future intruders in the process. You essentially turn your body into its own vaccine manufacturing unit.

Because RNA vaccines let your body do most of the work, they don’t require much material. That makes them much faster to manufacture. There’s a catch, though: we don’t know for sure yet if RNA is a viable platform for vaccines. Since COVID would be the first RNA vaccine out of the gate, we have to prove both that the platform itself works and that it creates immunity. It’s a bit like building your computer system and your first piece of software at the same time.

Even if an RNA vaccine continues to show promise, we still must continue pursuing the other options. We don’t know yet what the COVID-19 vaccine will look like. Until we do, we have to go full steam ahead on as many approaches as possible.

It might not be a perfect vaccine yet—and that’s okay.

The smallpox vaccine is the only vaccine that’s wiped an entire disease off the face of the earth, but it’s also pretty brutal to receive. It left a scar on the arm of anyone who got it. One out of every three people had side effects bad enough to keep them home from school or work. A small—but not insignificant—number developed more serious reactions.

The smallpox vaccine was far from perfect, but it got the job done. The COVID-19 vaccine might be similar.

If we were designing the perfect vaccine, we’d want it to be completely safe and 100 percent effective. It should be a single dose that gives you lifelong protection, and it should be easy to store and transport. I hope the COVID-19 vaccine has all of those qualities, but given the timeline we’re on, it may not.

The two priorities, as I mentioned earlier, are safety and efficacy. Since we might not have time to do multi-year studies, we will have to conduct robust phase 1 safety trials and make sure we have good real-world evidence that the vaccine is completely safe to use.

We have a bit more wiggle room with efficacy. I suspect a vaccine that is at least 70 percent effective will be enough to stop the outbreak. A 60 percent effective vaccine is useable, but we might still see some localized outbreaks. Anything under 60 percent is unlikely to create enough herd immunity to stop the virus.

The big challenge will be making sure the vaccine works well in older people. The older you are, the less effective vaccines are. Your immune system—like the rest of your body—ages and is slower to recognize and attack invaders. That’s a big issue for a COVID-19 vaccine, since older people are the most vulnerable. We need to make sure they’re protected.

The shingles vaccine—which is also targeted to older people—combats this by amping up the strength of the vaccine. It’s possible we do something similar for COVID, although it might come with more side effects. Health authorities could also ask people over a certain age to get an additional dose.

Beyond safety and efficacy, there are a couple other factors to consider:

How many doses will it be? A vaccine you only get once is easier and quicker to deliver. But we may need a multi-dose vaccine to get enough efficacy.

How long does it last? Ideally, the vaccine will give you long-lasting protection. But we might end up with one that only stops you from getting sick for a couple months (like the seasonal flu vaccine, which protects you for about six months). If that happens, the short-term vaccine might be used while we work on a more durable one.

How do you store it? Many common vaccines are kept at 4 degrees C. That’s around the temperature of your average refrigerator, so storage and transportation is easy. But RNA vaccines need to be stored at much colder temperature—as low as -80 degrees C—which will make reaching certain parts of the world more difficult.

My hope is that the vaccine we have 18 months from now is as close to “perfect” as possible. Even if it isn’t, we will continue working to improve it. After that happens, I suspect the COVID-19 vaccine will become part of the routine new-born immunization schedule.

Once we have a vaccine, though, we still have huge problems to solve. That’s because…

We need to manufacture and distribute at least 7 billion doses of the vaccine.

In order to stop the pandemic, we need to make the vaccine available to almost every person on the planet. We’ve never delivered something to every corner of the world before. And, as I mentioned earlier, vaccines are particularly difficult to make and store.

There’s a lot we can’t figure out about manufacturing and distributing the vaccine until we know what exactly we’re working with. For example, will we be able to use existing vaccine factories to make the COVID-19 vaccine?

What we can do now is build different kinds of vaccine factories to prepare. Each vaccine type requires a different kind of factory. We need to be ready with facilities that can make each type, so that we can start manufacturing the final vaccine (or vaccines) as soon as we can. This will cost billions of dollars. Governments need to quickly find a mechanism for making the funding for this available. Our foundation is currently working with CEPI, the WHO, and governments to figure out the financing.

Part of those discussions senter on who will get the vaccine when. The reality is that not everyone will be able to get the vaccine at the same time. It’ll take months—or even years—to create 7 billion doses (or possibly 14 billion, if it’s a multi-dose vaccine), and we should start distributing them as soon as the first batch is ready to go.

Most people agree that health workers should get the vaccine first. But who gets it next? Older people? Teachers? Workers in essential jobs?

I think that low-income countries should be some of the first to receive it, because people will be at a much higher risk of dying in those places. COVID-19 will spread much quicker in poor countries because measures like physical distancing are harder to enact. More people have poor underlying health that makes them more vulnerable to complications, and weak health systems will make it harder for them to receive the care they need. Getting the vaccine out in low-income countries could save millions of lives. The good news is we already have an organization with expertise about how to do this in Gavi, the Vaccine Alliance.

With most vaccines, manufacturers sign a deal with the country where their factories are located, so that country gets first crack at the vaccines. It’s unclear if that’s what will happen here. I hope we find a way to get it out on an equitable basis to the whole world. The WHO and national health authorities will need to develop a distribution plan once we have a better understanding of what we’re working with.

Eventually, though, we’re going to scale this thing up so that the vaccine is available to everyone. And then, we’ll be able to get back to normal—and to hopefully make decisions that prevent us from being in this situation ever again.

It might be a bit hard to see right now, but there is a light at the end of the tunnel. We’re doing the right things to get a vaccine as quickly as possible. In the meantime, I urge you to continue following the guidelines set by your local authorities. Our ability to get through this outbreak will depend on everyone doing their part to keep each other safe.

 

 

The first modern pandemic

The scientific advances we need to stop COVID-19.

 

What our leaders can do now

These decisions will affect the course of COVID-19.

 

31 questions and answers about COVID-19

My thoughts on what to do now and other topics.

 

© 2020 The Gates Notes


By Bill Gates

May 12, 2020 5 minute read


In any fight, it’s important to know your enemy

Unfortunately, in our battle against COVID-19, there’s a lot that we still don’t know.

How many people are infected with the virus, including those without symptoms?

Is it seasonal or weather dependent?

And how will we know when it might be safe to get back to work and send kids back to school?

These are important questions. More testing, of course, will help us answer them. But with tests in short supply in many parts of the world, including the U.S., it is impossible to test everyone—at least for now.

That’s why I’m excited about a new disease surveillance program in the Seattle area to detect cases of COVID-19 and help guide public health responses. Not only will it help improve our understanding of the outbreak in Seattle, it will also provide valuable information about the virus for other communities around the world.

The greater Seattle Coronavirus Assessment Network—or SCAN—is a first-of-its-kind disease surveillance platform for COVID-19 that allows participants to use a self-swab test to collect their own nasal samples and send them to a lab without leaving home. As a surveillance program, SCAN’s goal isn’t to test every person or serve as a replacement for medical care. Instead, SCAN is testing a sample of people in the Seattle region, including those who are healthy as well as those who are feeling sick. The test results and other data (like a person’s age, gender, race, zip code, and any underlying health conditions) are used by researchers, data modelers, and public health officials to paint a clearer picture of how COVID-19 is moving through the community, who is at greatest risk, and whether physical distancing measures are working.

One of the biggest questions puzzling public health officials is exactly how many people are infected with the virus. Think about the pandemic like an iceberg, says Dr. Jay Shendure, scientific director of the Brotman Baty Institute, one of SCAN’s lead partners. With ongoing COVID-19 medical testing, which has been largely focused on people with symptoms, we have been able to see the tip of the iceberg. Just below the surface, however, there is the part of the iceberg we don’t see—the unknown number of people who are infected but experience mild symptoms or no symptoms at all. Dr. Shendure compares SCAN to “a set of sonar pings where we’re skimming over the water and pinging to see what lurks beneath.”

I want to be clear that SCAN does not replace the widespread testing that is still needed in communities. But it has the potential to become an important tool for health officials seeking insights about the spread and behavior of the virus. Early results from SCAN found many cases of COVID-19 in Seattle that might otherwise have gone undetected among individuals who had experienced some symptoms (fever, cough, or shortness of breath) but had not yet sought medical care. As SCAN gathers more test results in the weeks ahead, researchers expect the new data to provide a better sense of the number of infections and serve as one source to help answer other questions, like when physical distancing measures can be relaxed.

SCAN is a partnership between Public Health—Seattle & King County, the Brotman Baty Institute, University of Washington Medicine, Fred Hutchinson Cancer Research Center, and Seattle Children’s Hospital. It relies on data modeling support from the Institute for Disease Modeling (IDM) and receives support from my private office, Gates Ventures, and our foundation.

SCAN is an outgrowth of a research study started before COVID-19. It’s been clear for years that there was a lot the scientific community didn’t understand about respiratory viruses, such as how they spread through a community, and the best ways to stop them. So, in 2018, my office teamed up with the Brotman Baty Institute and other partners to launch a study of respiratory illnesses, including the seasonal flu. That effort, the Seattle Flu Study, aimed to recruit 10,000 volunteers in Seattle who showed cold symptoms to provide a simple nasal swab at kiosks set up in health centers and through at-home tests.

One of the early discoveries of the study was the impact of high-intensity physical distancing measures on reducing the flu. In the winter of 2019, a major snowstorm in Washington state led to week-long school and workplace closures. Analyzing the data from that flu season, researchers found that the snowstorm’s dramatic disruption of social contact led to a drop in the transmission of the flu and other respiratory illnesses.

The Flu Study team hoped that these and other findings would help researchers develop tools to curb and even prevent the spread of the flu—and maybe one day help public health officials prepare for a future pandemic.

That day arrived sooner than anyone ever imagined with COVID-19.

In late January 2020, the first confirmed case of the novel coronavirus appeared in the U.S., just outside Seattle. The patient had visited Wuhan, China, the origin of the outbreak. 

Several weeks later, the Seattle Flu Study team started picking up signs of the coronavirus’s genetic signature in their flu study survey samples. In February, they identified the first known case of transmission in the U.S.—a teenager living outside Seattle who had not traveled to China and had no link to anyone with the virus. The Flu Study team sequenced its genome, and quickly realized that the virus had been spreading undetected for weeks.

This finding and the discovery of dozens more coronavirus cases suddenly put the Seattle Flu Study at the center of the area’s response to the coronavirus. We were fortunate to have this existing surveillance platform and an experienced team to quickly shift their focus to the outbreak. In March, we formed the new SCAN partnership with King County’s public health agency to track the spread of COVID-19.

One of the innovations of SCAN is an easy-to-use, at-home, self-swab test kit. The key advantage of this at-home testing approach is that people don’t need to go to a clinic, where they risk exposing themselves or others to infection. People interested in participating in SCAN can enroll online, and, once approved, they get a test delivered directly to their home. After individuals complete the nasal swab test, a courier service picks it up from their home and returns it to SCAN for processing. Anyone who has a positive result gets contacted by a public health worker who provides guidance on how to care for themselves and their families. And all participants can check their results online.

SCAN is currently testing 300 people per day, but actively working to test more. Those test results are then analyzed by disease modelers to map virus transmission chains. By examining the genetic signature of an infection, they can determine whether it represents a new introduction to the region or is part of a local transmission. They can also use the data to estimate disease prevalence and build models to look at how the virus is responding to certain measures—like school closures and physical distancing. You can learn more about their work on Nextstrain and the Institute for Disease Modeling’s research site.

As the SCAN team collects more data, I’m looking forward to learning more about their insights into many of the questions we have about this pandemic and how we can prevent the next one.

 

 

What you need to know about the COVID-19 vaccine

Humankind has never had a more urgent task than creating broad immunity for coronavirus.






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