1. The treatment endgame. We learn to live with the virus. Deaths are prevented using treatments.
2. The suppression endgame. We keep people from coming into contact with the virus.
3. The immunity endgame. Enough people get the virus and/or a vaccine so that it has few people to infect.
It sounds like (2) works in some countries, using ots of testing, tracing, and quarantining. Many people are angry that the U.S. has not executed this strategy. But (a) a lot of other countries also have not been able to execute it and (b) it seems like a fragile strategy, in that at some point you could experience too many cases to deal with using testing and tracing, and then where are you?
Lockdowns were supposed to be part of (1), the idea being to “flatten the curve” and ensure enough treatment resources. I have speculated on a super-strict short-term lockdown to achieve (2), but that is probably a fantasy. Meanwhile, many people seem to have come to believe mistakenly that the lockdowns that we actually have can achieve (2).
I thought that (1) was more likely to work than (3). But events seem to be moving in the other direction. We see have seen deaths rise pretty dramatically in recent weeks. Not to NY/NJ nursing home levels, but still alarming. So the treatments have not yet reached the point where we can just live with the virus as we can with the flu.
To my knowledge, herd immunity has not emerged anywhere. That leaves the vaccine.
Vaccine trials seem to show efficacy. As you know, I worry that the results might not be reliable, because even in the placebo sample there were not many cases. But my guess is that since mid-November there have been many more cases, and if the results are still strong then that would be pretty convincing.
I suggested the other day that challenge trials could have been used to more efficiently demonstrate efficacy of the vaccine. But there is an argument that there is no way to evaluate safety quickly. If the vaccine is going to have harmful effects, these may take a while to show up. So perhaps we could not have evaluated a vaccine in a matter of weeks, even with challenge trials.
Guessing the vaccines will not be 100% efficacious in response to the epidemic necessitating more work on treatment and no end in sight to the social distancing/masking/shutdown regimes.
The virus seems to allow the new civic religion an opportunity to express its Islam-like tendencies. Submission is the bottom line. That requires mullahs and police. Face coverings to extinguish individualism. Conformism in nearly every aspect of life. Every time terrorists killed a bunch of people, the elite reaction was always dread that somewhere some unenlightened soul might say something to hurt a Muslim’s feelings. Now we know why.
“necessitating more work on treatment and no end in sight to the social distancing/masking/shutdown regimes.”
If so this is existential and we might as well go down fighting. I’ve accepted that I might have to put up with this bullshit for another couple of months until a good chunk have the vaccine. If they try to push beyond that I think I’ll go insane.
I agree on the religious nature of the lockdown crowd. In a way I wish that the vaccine didn’t work, it would force a decision point. We will be getting respiratory viruses with COVID-19s profile with some regularity, I hope we don’t do this every time.
1) “It sounds like (2) works in some countries, using ots of testing, tracing, and quarantining.”
Which countries have had lots of testing and tracing? Korea has been the second lowest tester in the OECD, above Japan at the bottom where the U.S. has been testing at 20 times the rate of those two countries this month.
2) “To my knowledge, herd immunity has not emerged anywhere. That leaves the vaccine.”
Herd immunity may not be anywhere in the U.S. but there will be several months before much of the country has been vaccinated and herd immunity could appear sometime between January and May.
“Herd immunity may not be anywhere in the U.S. but there will be several months before much of the country has been vaccinated and herd immunity could appear sometime between January and May.”
And if herd immunity and/or the vaccine turn out to have transient efficacy then what? Perhaps the best strategy has always been (1). There’s of course the possibility that covid behaves like the Spanish Flu and just more or less vanishes after another year or so.
As usual, I agree pretty much with your analysis, but I have two small comments.
“So the treatments have not yet reached the point where we can just live with the virus as we can with the flu.”
This is true and it has always been my main concern with the NPI approach to the pandemic. By focusing on quixotical measures to contain the disease by reducing contagions, the mitigation and prevention of the consequences of the disease have been neglected.
“To my knowledge, herd immunity has not emerged anywhere. That leaves the vaccine.”
Are we sure about that? Based on the evolution of the second wave in Spain, it looks like Madrid, the city where I live and was the epicenter of the spring outbreak, has already entered the endemic phase, typical of any seasonal disease caused by a respiratory virus. This implies that herd immunity was almost reached by summer, notwithstanding the severe lockdown imposed upon us. A similar situation seems to happen in northern Italy and Stockholm. I encourage you to look at regional data available in the US to see if you can spot the same pattern.
With respect to the vaccine, I remain skeptical. It might be a useful excused for politicians to end the panic and proclaim that we were saved by them. But in terms of its real public health benefits, I fear that they will be little.
Maybe we need a term like “herd immunity lite”. Where around 2X% infection rate most of the super spreaders have gotten it so growth stops being scary and exponential even if the virus doesn’t totally disappear.
I was going to make the same comment regarding Sweden, and Stockholm in particular. Here are the percentages for the growth in Covid deaths for selected European countries for November:
Sweden: 10.6%, Denmark: 12.9%, the Netherlands: 19.3%, Spain: 23.2%, Russia: 40%, Poland: 194%, UK: 24.2%, Germany: 52.3%.
About US regional data, I’ve looking at New York state data for the last few weeks, and besides the fact that the growth in deaths seems to be lower than for other states, growth in cases and deaths is also lower in the city of NY than in the rest of the state. Also, Bronx and Queens have what is probably the highest death rates per 100,000 population in the world (241.6, 229.6) but their rates seem to be growing very slowly.
I guess it depends on what is Arnold’s definition of “herd immunity”.
https://news.yahoo.com/swedish-government-sidelines-epidemiologist-steered-102636440.html
Sweden ranks #22 in Covid-19 deaths per capita despite having, along with the U.S. and the U.K., the most liberal labeling of a Covid-19 death.
“This month, though, the number of deaths in Sweden has again begun to soar above that of its Nordic neighbours,”
Again, percentages for the growth in Covid deaths for nordic countries:
Finland: 7.2%
Sweden: 10.6%
Denmark: 12.9%
Estonia: 53.4%
Iceland: 62.5%
Norway: Can’t find data.
That doesn’t look like soaring to me. It looks more like a political decision.
Regarding Tegnell’s strategy, I don’t completely agree with it. In fact I think he’s on record for underestimating the death rate of Covid (0.30% – 0.37% as far as I know) in the first months of the pandemic. But regardless of that, the numbers seem to imply that his strategy has brought Sweden closer to herd immunity.
Looking at national numbers is very misleading. You need to focus on smaller regions.
It is becoming more and more obvious that this virus spreads very fast at the beginning -reaching the whole world in less than 2 months- propelled by super-spreaders.
The existing social networks, lockdowns and other NPIs help create pockets of vulnerable populations, that become infected as soon as the restrictions disappear or simply as a consequence of travels into these pockets.
Gradually, these pockets will be disappearing.
In parallel vaccines with an unknown efficiency will start to be distributed. A further reduction in the number of deaths will be observed.
The effect of the vaccines will never be known, but they will be credited with suppressing Covid.
And Andrew Cuomo got a COVID award for killing all those nursing home patients.
“So the treatments have not yet reached the point where we can just live with the virus as we can with the flu.”
Eh, I disagree. I think we have to learn to live with it. The numbers don’t justify all the measures we have taken. You need epidemiologist worst case March projections to justify all this, and we are orders of magnitude below that.
I suspect the vaccine looks good enough to end the pandemic.
The question though is if this is the new benchmark for behavior. We will surely see other respiratory viruses with COVID-19s profile in the future. Are we going to go into hysterics and lockdowns even single time? In a way the vaccine prevents us from confronting that question, and we might not get a vaccine next time.
“The question though is if this is the new benchmark for behavior. We will surely see other respiratory viruses with COVID-19s profile in the future. Are we going to go into hysterics and lockdowns even single time?”
Yes we will, provided that the baby boomers get to dictate policy. Most irrational response in the history of mankind. 40% of the deaths are linked to those already in nursing homes. 40% of the cases are completely asymptomatic and 80% of the symptomatic cases are completely mild. We are gonna upend everything for this? Uh…ok.
So yeah, I’m voting for the vaccine. 50% effective? 70%? 90+%. Who frigging cares.
I share the skepticism about our over-reaction to the Covid disease.
However I do not think it can be ascribed to “baby boomers.” I find that there is a broad spectrum of opinions on lockdowns in all age groups. Sweden and Australia have had utterly different strategies, though I suspect that both are managed by baby boomers.
The key question here is why we did not shut down the economy during medical crises in prior decades that were just as severe. I think that the answer lies in part in social media. I suspect that the average person and average politician in the 1950’s did not even know we were having an epidemic.
I don’t think it’s social media. I think it’s a lot deeper than that. All modern economies seem to undergo a “demographic transition”. In olden times, people had many children because many of them wouldn’t survive. Losing children, while hardly desired, was accepted as the way things are. But now people think it is natural for everyone to survive until 70 or later. Thus, the virtual disappearance of large families.
Until recently, it was natural and expected that a significant number of people would die from infectious diseases. So the flu deaths in the ’50s were background noise. Not today!
If I were asked to give a date for when the new expectation became predominant, I would nominate a little after the widespread use of the new polio vaccines in the ’60s. At that point, there were immunizations for all the scourges of temperate mankind. Children got them as a matter of course during their fist decade of life.
In the ’50s, people were also closer to the depression. But more than that, all their ancestors had considerably lower standards of living. Prosperity and affluence was not a taken-for-granted expectation. The idea of “shutting the economy down” would have been considered inhuman.
Good points.
Another factor since about 1980 (I think) is the incredible improvements in hospital ICU care.
People have been saved from previously fatal heart attacks, previously fatal sepsis, et al, in relatively great numbers.
Even today, ICU’s are literally pulling people back from death from covid in some cases. One reason we are facing a hospital crisis is that many covid patients must stay 15 days in an ICU, This is a tremendous strain on hospitals.
Believe me, no flu patient in the 1950’s got 15 days of dialysis and ventilators and intubation and powerful drugs.
My worry isn’t that the vaccine won’t work (I suspect it will). My worry is that we will have viruses just like this at regular intervals, and we can’t (well, we might even if we can’t) shut down every single time and hope a vaccine comes out at some point.
The end game happens when we are all exposed to the virus. Some get a large amount of inoculant and get sick others get a small amount and develop some immunity. Gradually we all become less susceptible. We may still get sick as we are exposed multiple times but the impact is lessened as our immune systems adapt.
What about combinations? Why must an endgame fall into one of these discrete categories?
Also, on vaccine skepticism, have you been keeping up with the side-effects-effect? It seems that they are sufficiently prevalent that those who receive actual vaccines know it, so efficacy reports are likely *understated* due to the Peltzman effect.
I think it is pretty clear that our endgame will involve a combination of the 3 categories.