Sunday, January 10, 2021

Our war against COVID-19, 2020-2021

 Last update: Monday 1/11/21
Thus far, the U.S. war against the coronavirus has been conducted in two phases. Phase 1 began in early February 2020 and ended in early December 2020. We entered Phase 2 in mid-December 2020 with the approval of two vaccines and with the emergence of significant COVID-19 mutations that were far more infectious than previous versions.


A brief review of the ambitions and shortfalls of the strategies for coping with the virus that were employed in Phase 1 provides a conceptual framework for speculations about what might be expected in Phase 2.

Phase 1
The U.S. was ill-prepared to cope with COVID-19 when the first cases were detected in early February 2020. A computer model created by Imperial College in the United Kingdom predicted that, if left unchecked, the virus would quickly overwhelm the health care systems in the U.S. and in the UK, especially their hospitals, and would result in millions of deaths. 
  • Imperial College (London) ... Report 9  (3/16/20)
It was well understood that the pandemic could not be stopped until effective vaccines had been developed and a high percentage of the population had been vaccinated. Therefore the immediate objective was to slow the spread of the virus so that the number of new cases that required hospitalization each week would stay below the maximum capacity of the hospitals in our states and local communities. Ideally the number of hospitalizations in a community would not increase from one week to the next, i.e., the curve of hospitalizations vs. time would "flatten" at a level below the maximum hospital capacity.

Epidemiologists and experts in related fields determined that when an infected person exhaled, a nearby uninfected person was likely to inhale some of the exhaled breath of the infected person that contained the virus. Therefore an obvious way to slow the spread of the virus was to encourage people not to get too close to other people in public places. Encouraging people not to get closer to other people than this social distance -- specified as six feet in the U.S. -- became the most important recommendation in the social mitigation guidelines recommended by the White House coronavirus task force.
  • President Trump, "Proclamation on Declaring a National Emergency Concerning the Novel Coronavirus Disease (COVID-19) Outbreak", White House, 3/13/20

  • "Trump Urges Limits Amid Pandemic, but Stops Short of National Mandates",  Katie Rogers and Emily Cochrane, NY Times, 3/16/20
The guidelines were subsequently amended to include the wearing of face masks. 
  • Affordable, readily available cloth masks offer limited protection to their wearers from the virus in the exhalations of nearby infected persons; but they can greatly reduce the amount of virus contained in the exhalations of their wearers. 

  • Requiring everyone to wear masks in public became a plausible mandate when it was discovered that people infected by COVID-19 could infect other people before they showed any symptoms. Indeed, some infected people never showed any symptoms which meant that no one could ever be sure they were not infected, even if they had recently tested as negative. 

  • Therefore if everyone in public places wore face masks, especially indoors, the total amount of virus floating in everyone's exhalations would be greatly reduced. In other words, everyone would protect everyone else. 

  • "C.D.C. says all Americans should wear masks. Trump says the rule is voluntary.", NY Times, 4/3/20
Unfortunately, social mitigation had two significant characteristics that greatly impeded the achievement of its strategic purpose.
  • Damage to local economies
    There is an inescapable correlation between people's exposure to potential infection and their demand for the goods and services of their local communities.  Social distancing reduces people's exposure to the virus by greatly reducing the maximum number of customers who can sit in a bar or restaurant, attend a movie, go to a ballgame etc, etc, etc. These forced reductions in customer demand greatly reduce the incomes of the affected businesses.  Their owners will reduce their expenses by laying off some staff; but if the restrictions last long enough, the owners will be forced to close their businesses and lay off all of their staff. The more businesses covered by the restrictions and the longer the restrictions are imposed, the greater the number of business failures and the greater the number of people who become unemployed. Lockdowns restrict all non-essential businesses so they have the most devastating impact on local economies.

    In mid-March, 2020, the White House task force appealed to everyone in the country to shelter at home if they were not essential workers. At that time there were less than 20,000 infected persons in all fifty states, and significant numbers of infections were only evident in a handful of states. This national lockdown was not mandatory, but millions of people people in all fifty states sheltered at home. The aggregate impact of these millions of individual decisions dealt a devastating, long-lasting blow to local economies in all 50 states. Unemployment soared to more than 30 million and cost trillions in taxpayer dollars to keep it from soaring even higher. A detailed review of this lock step national lockdown can be found in another note on this blog:

    "Where do we go from here?", Last update: 10/30/20

  • Conflicts with deeply ingrained habits
    Social mitigation guidelines that keep people away from each other conflict with deeply ingrained social and workplace habits, habits rooted in the gregarious nature of human beings. Therefore the expertise of the members of the task force in epidemiology and related biological sciences did not qualify them to assume leading roles in ongoing efforts to induce an overwhelming majority of the population to adhere to mitigation guidelines for long periods of time.

    Judging by their presentations on their TV shows, the task force saw themselves as "professors" and their viewers as "students". The "professors" specified the new behaviors that student viewers had to learn in order to control the virus; then they applauded their student viewers when they learned, but chided them when they failed to learn, as evidenced by subsequent decreases or increases in COVID infections, hospitalizations, and deaths.

    Unfortunately, the college metaphor is misleading. On the one hand, substantial learning actually occurs in most classrooms; whereas t    he recurring spikes and surges in U.S. infections, hospitalizations, and deaths since March 2020 suggests repeated failures to learn. A metaphor that provides a better fit to these failures is "fat shaming". Learning occurs in classrooms, but "fat shaming" has never helped anyone change their eating habits; so no one should have expected better results from "COVID shaming".

    A detailed description of an alternative type of task force that would use more effective methods to induce sustained adherence to social mitigation guidelines can be found in another note on this blog:

    "We need a different kind of coronavirus task force", Last update: 11/28/20

Phase 2
Whereas Phase 1 was defined by social mitigation, Phase 2 is likely to be defined by the interactions of mitigations, mutations, and vaccinations. Vaccines were supposed to end the need for social mitigation by halting the spread of the virus via herd immunity. The first two vaccines were approved in December 2020
  • "New Pfizer Results: Coronavirus Vaccine Is Safe and 95% Effective", Katie Thomas, NY Times, 11/20/20

  • "Moderna’s Covid-19 Vaccine Is 94.5% Effective in Early Results, Firm Says", Peter Loftus, Wall Street Journal, 11/16/20
Shortly thereafter, significant new COVID-19 mutations were detected that spread much faster than previous mutations. Fortunately, our experts anticipate that these new mutations will still be blocked by current vaccines. But unfortunately, their appearance will trigger higher spikes and surges that will require stricter mitigations that will cause larger disruptions to the nation's local economies. Otherwise the nation's health care systems will be overwhelmed long before a high enough percentage of the population has been vaccinated.
  • "South Africa announces a new coronavirus variant.", Sheri Fink, NY Times, 12/21/20

  • "Here’s what we know about the new European coronavirus mutation", Meryl Kornfield, Washington Post, 12/20/20

  • "Discovery of Virus Variant in Colorado and California Alarms Scientists", Apoorva Mandavilli, NY Times, 12/30/20
The complexity of these interactions has been compounded by slow rollouts of the initial supply of the vaccines:
  • "Here’s Why Distribution of the Vaccine Is Taking Longer Than Expected", Rebecca Robbins, Frances Robles and Tim Arango, NY Times, 12/31/20
A familiar unreadiness adds yet another layer of complexity -- vaccine hesitancy
  • "KFF COVID-19 Vaccine Monitor: December 2020", Liz Hamel, Ashley Kirzinger, Cailey Muñana, and Mollyann , KFF, 12/15/20
    ... "    About a quarter (27%) of the public remains vaccine hesitant, saying they probably or definitely would not get a COVID-19 vaccine"
That 27 percent of the population is vaccine hesitant is worrisome given Dr. Fauci's recent estimate that about 90 percent of the population must be vaccinated in order to achieve the herd immunity required to end the pandemic
  • ''How Much Herd Immunity Is Enough?", Donald G. McNeil Jr., NY Times, 12/24/20
The final complexity that should be anticipated is the emergence of a "Groundhog Day" mutation, i.e., a mutation whose spread is not blocked by current vaccines. It is so named because, as in the 1993 Bill Murray movie, it would suddenly transport us back to the beginning of Phase 1 in early February 2020, before vaccines had been developed, a time wherein our only defense was social mitigation.

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