What is to be done?

We need enough lockdown and social distancing  to drive the R0 below 1.0 – that doesn’t require much more effort than the intensity required to ‘flatten the curve’ and it has an enormous payoff – new cases fade away instead of growing ! Like I said, there is no substitute for victory.

But we don’t want that lockdown to persist forever – it’s incredibly expensive. I estimate that China has lost >  hundreds of billions of dollars in their current freeze. We will too:  and judging from the course of events in Italy, we’ll have to impose pretty severe  lockdown if we want to get transmission under control.   Maybe it won’t have to be as severe as in China or Italy – the US has some favorable factors, mainly lower population density and more private cars ( as opposed to public transportation).

All this must be paired with a crash program to develop effective therapies and/or means of prevention.  If someone has an idea for a new drug, or a new method of treatment, he should rethink it and ask if it could be accomplished in half the time with twice the money, or for that matter with ten times the money. We should fund every plausible approach, a bit like the Manhattan project.   Some would be surprising: for example, there is evidence that already having one viral disease ( say influenza) can reduce your chances of catching another – true at both the population and individual level, perhaps because your interferon is revved up.  Old-fashioned approaches ( like serum therapy ) might be revived.  We can scan the existing pharmacopoeia for something useful: we can mine HMO data to see if some common drug is already having a positive effect.

The US has the world’s strongest biomedical research community.  We can do this – and we won’t be alone.

When we succeed, the lockdown will soon end. With a treatment or some form of prevention, we won’t have to worry about the ongoing cases in other parts of the world – and we could then help the rest of the world, which is no bad thing.

Cost is no object: there is no way to spend money on biomedical research that is in any way comparable with the cost of lockdown.

One advantage: we can cut some corners, because coronavirus is so dangerous.  We thought vaccination against smallpox too hazardous ( a disease extinct in the wild, and a vaccine that killed 1 in a million of those vaccinated and made about 1 in 100,000 seriously ill). In today’s situation, facing coronavirus, that level of side effect could perhaps be tolerated, at least until we came up with something better.

Careful analysis and simulation can minimize the cost. China has cut the R0 down to 0.3, but that’s overkill: at this point a relaxation that allowed some business to operate and pushed the R0 up to 0.8 would be fine.  The rate of new cases would not increase from the current low level. If we relax a bit too much, R0 might creep  a bit above 1.0, but with lots of testing and monitoring we could fix that before it caused much trouble.

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74 Responses to What is to be done?

  1. Anyone know why serum therapy is not being discussed more as ‘the solution’? Every article you read notes that a vaccine is >1 year away, but serum therapy seems like the obvious solution. Takeda are pursuing TAK-888 but even that seems fairly high tech: is it really necessary if we’re going to want millions of doses by the end of April? There’s already >60,000 survivors so presumably if a good fraction of them donated, that should save a huge number of people (even if some people don’t respond). Are there downsides? I can imagine a risk of transmitting other diseases if it’s scaled up in a rush… seems remotely plausible that it could increase risk of autoimmune disorders if you’re giving large numbers of people a random mix of polyclonal antibodies… but these all seem preferable to rejecting to treat people >65 at all because there are no hospital beds.

    • Анисимов Дмитрий says:

      What if large fraction of these survivors are now-asymptomatic carriers?

      • gcochran9 says:

        There is no particular reason to expect that.

      • amac78 says:

        What if large fraction of these survivors are now-asymptomatic carriers?

        This question can be definitively answered by giving infected patients a pair of tests, repeatedly, over a period of a couple of weeks. One test is a molecular diagnostic for the presence of viral RNA in sputum or blood. The second is a serological test that assays the patient’s anti-covid19 antibodies. A positive result says that the patient is currently, or has in the past, defended against covid19.

        Asymptomatic carriers (or long-term symptomatic carriers) would obviously have a particular profile.

        This has been done for coronaviruses and for covid19, and nearly all patients who mount a reaction against the virus, clear it. Sorry, I don’t have the references, and the covid19 results are AFAIK all by Chinese researchers, mostly available as preprints. Nearly all is likely to be effectively all (per Greg Cochran’s answer). Obviously, it takes a properly powered sample to know for sure.

        That the question hasn’t been definitively answered in the US is one more very-bad consequence of the CDC/FDA/Trump screwup, needlessly and heedlessly delaying the development, validation, and distribution of covid19 diagnostics.

      • amac78 says:

        Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. by Fei Zhou et al., The Lancet, published online March 9, 2020. <a href="https://www.thelancet.com/pb-assets/Lancet/pdfs/S014067362305663.pdf"<PDF download.
        Data on 191 patients (54 non-survivors and 131 survivors). These were generally very sick patients transferred to an advanced care setting, early in the epidemic. “Duration of viral shedding ranged between 8 and 37 days. The median duration of viral shedding was 20 days in survivors, but continued until death in fatal cases.”

        Not clear on a fast read whether or not infectious virus continued to be shed after symptoms were resolved. I think the 37 day figure means “not”.

    • tc says:

      China is sending serum in its aid package to Italy.

      CORONAVIRUS UPDATE: CHINA EASTERN AIRLINES’ A350 DEPARTED FOR ROME, ITALY FROM SHANGHAI, BRINGING 9 CHINESE MEDICAL EXPERTS AND 31 TONS OF MEDICAL SUPPLIES, INCLUDING PLASMA OF RECOVERED CORONAVIRUS PATIENTS, TO HELP ITALY FIGHT AGAINST THE VIRUS – GT

  2. Magus says:

    When was the last time the US Government did something remotely efficient? Not being difficult genuinely curious. Rebuilding the freeway in La after the earthquake maybe? First Gulf War under Manstein 2.0?

    Respectfully I don’t think the current USG has the capacity to organize or do anything of the sort you’re recommending. Not without major reforms to improve state capacity/governance. This isn’t the 1950s govt anymore. Heck it’s not even the 1970s government anymore.

    • Boswald Bollocksworth says:

      Indeed, it looks as though the “HR department” types have disastrously gummed up the works of the relevant agencies. For example the inability of government to organize new, rushed N95 mask production and test kit production is criminal. We’ve know for two bleeding months this sumbitch was coming for us. Still no effective testing.

      We need to all be in masks when in public and running waves of testing. They just don’t seem up to it. I think the oligarchs will come to the rescue. Bezos needs us alive.

    • Nuke The Curve... But Don't Got The Nukes says:

      Quite. US can’t manage a travel ban on coronavirus in early stages, but it can manage massive track and trace and quarantine and lockdown, sustained for months and months, if not a year, and develop cures in quick-time?

      Who sees any of this as possible? Probably not the same commentators who believe the US has the most crazy-infested and systematically reality denying government in its history.

  3. Tim Burr says:

    ” … and we could then help the rest of the world, which is no bad thing.”

    The rest of the world hasn’t been too gracious about our help in the past. I think Americans have mixed feelings about a big program like this. And not a lot of team spirit.

    But maybe it can be sold as a program to make positive changes to the medical system which will help us as individuals. Self-interest. But not on the “helping others” basis.

  4. Mycroft Jones says:

    Be interesting to see some research and development done on phages.

  5. James Garder says:

    I think, as Brazil ‘s President, Captain Bolsonaro, pointed out, much exaggeration. The new coronavirus is barely worse than the common flu.

  6. Pingback: What is to be done? — West Hunter | The zombie apocalypse survival homestead

  7. gothamette says:

    Colorado now has a drive-in testing site.

    Prediction: NYC with its huge concentration of wealth, will lag, and become Lombardy.

  8. Anonymous says:

    Somewhat OT, but yet another Doctor finds that a rheumatoid arthritis drug works against cytokine storms. It is not the virus that kills most people, but the body’s overreaction to the presence of the virus.

    http://www.ansa.it/english/news/2020/03/11/arthritis-drug-seems-to-work-on-the-coronavirus_94a197aa-8acf-4706-9ecc-4d887b5f8e48.html

  9. j says:

    I shared President Trump’s hope that this epidemic would behave like the flu and disappear around May. But the corona-virus seems to thrive in all seasons; in Australia it is summer now and they have people sick and dying. Some influenza virus are protected by a lipid envelope that melts in hot weather, is the corona different? Regarding the vaccine, we used to have the vaccine ready a few days after the season’s dominant variety was identified, while now it is taking months. Why?

    BTW, https://ourworldindata.org/coronavirus has a table showing the days it takes to double the number of “cases” – and there are many countries where it doubles in 2 days. Frightening!

  10. jbbigf says:

    You realize that exactly none of that is going to happen, right?

    • Toddy Cat says:

      Actually, most of it probably will happen, but in a confused halting manner, with much unnecessary spending of money, loss of life, and bureaucratic bungling, which will end with the US having the best anti-coronavirus program in the world, just about the time the crisis ends. This is simply the way the US works, unfortunately. The first six months to a year of every major war the US has ever fought (barring walkovers like the Mexican War, Spanish-American War, and GW 1) has been an absolute sh*tshow, and I see no reason why this should be any different. We’ll get through this, possibly triumphantly, but at far higher cost than necessary. It doesn’t have to be like this, but somehow, it always is…

      • j says:

        An Israeli lab in Galilee, MIGAL, examined the novel virus and found that the poultry coronavirus has high genetic similarity to the human one (and we blamed innocent fruit bats and pangolins!), and that it uses the same infection mechanism, which increases the likelihood of achieving an effective human vaccine in a very short period of time. We may beat the Chinese and the Americans in producing a vaccine. The race is on.

  11. James K says:

    Suppose we follow the Wuhan model, have a strict lockdown, and eliminate new cases after 5 weeks. After 9 weeks the country will be virus-free, but most people will not have immunity. If we then remove the lockdown measures, including travel restrictions, would the epidemic simply resume?

    In other words, to be effective, must the lockdown continue until the pandemic has run its course worldwide (possibly taking more than a year)?

    • Hugh Mann says:

      Looks like Boris Johnson has decided that killing off his voters is the thing to do. Can’t keep the economy locked, those oldies have to go!

      “First thing we do, let’s kill all our voters”

      https://www.itv.com/news/2020-03-12/british-government-wants-uk-to-acquire-coronavirus-herd-immunity-writes-robert-peston/

      “The strategy of the British government in minimising the impact of Covid-19 is to allow the virus to pass through the entire population so that we acquire herd immunity, but at a much delayed speed so that those who suffer the most acute symptoms are able to receive the medical support they need, and such that the health service is not overwhelmed and crushed by the sheer number of cases it has to treat at any one time.

      The government’s experts – the chief medical officer and the chief scientific advisor – have made two big judgements.

      First, as the World Health Organisation on Wednesday in effect conceded, that there is no way now of preventing the virus sweeping across Africa, Asia and the Americas – which in practice means that it will be an ever-present threat to the UK, unless and until a mass vaccine is available for use.

      Second, the kind of coercive measures employed by China in Wuhan and Hubei have simply locked the virus behind the closed doors of people’s homes.

      And just as soon as the constraints on freedom of movement are lifted there, the monstrous virus will rear its hideous face again.”

      • James K says:

        “Second, the kind of coercive measures employed by China in Wuhan and Hubei have simply locked the virus behind the closed doors of people’s homes.”

        After 9 weeks, the people behind locked doors are either healthy and non-infectious, or dead and buried.

        “And just as soon as the constraints on freedom of movement are lifted there, the monstrous virus will rear its hideous face again.”

        I suspect that the problem would be reinfection from outside the lockdown zone, not people emerging from their homes.

      • “Think of it as evolution in action.”

  12. Curtis says:

    Why doesn’t the CDC (or any western nation) have a supply of a few billion surgical masks? Or better yet, the ability to make billions of masks quickly? If your biggest job is to prevent pandemics, this would seem like the first thing you need to do. In some towns in Italy, all the doctors have the virus and no masks to prevent themselves from spreading it to their patients.

  13. Abelard Lindsey says:

    The long term solution to infectious disease is increased host resistance. That is to increase the strength of people’s immune systems. The best approach to accomplishing this would be to fully fund Aubrey de Grey’s SENS work as well as develop cellular reprogramming (AgeX and Turn.bio). Nothing less than this will do.

  14. Richter says:

    This post should be our national rallying cry.

  15. Follow up post with some modeling of the costs of controls and costs of disease: https://arguablywrong.home.blog/2020/03/12/epidemiological-modeling-costs-of-controls/

    It’s very back of the envelope, but I get a $15 trillion cost to the US of an uncontrolled epidemic, , $7.5 trillion cost if we “flatten the curve”, and $3 trillion cost if we “nuke the curve”

    Greg’s right. Gotta impose a lockdown ASAP.

    • James K says:

      I like your analysis, and Greg’s, but “nuking the curve” would leave us without mass immunity, and in danger of reinfection. Your post mentions the possibility that low numbers of infections could be handled by a low-cost regime of contact tracing and targeted quarantine.

      But even if we could “nuke the curve” in one country, is it even possible to remain in the low-infection regime while the pandemic continues elsewhere? In 2018, US airports transported over 100 million passengers on international flights (in each direction). Unless we plan a long-term shutdown of international air transport, then to avoid unacceptable levels of re-infection we would need accurate rapid-response testing, large-scale test facilities at international airports, and (realistically) longer passenger check-in times to allow for the tests.

      I was surprised myself when I looked up the air passenger figures.
      https://www.bts.dot.gov/newsroom/2018-traffic-data-us-airlines-and-foreign-airlines-us-flights

      • Shutting down most international travel would not be terribly difficult, and would be substantially cheaper than the trillions of dollars an uncontrolled epidemic or a full lockdown of the economy would cost.

        • James K says:

          I agree about the cost issue. However, a shutdown might be more difficult than you think. Even if 99% of international travel were canceled, there would still be nearly 3,000 people entering the country every day. Without either a 100% shutdown, or some kind of testing or quarantine of arrivals, infected passengers would quickly overwhelm the “low-infection regime”.

          Would any other measures be needed? We might train hundreds or even thousands of people in contact tracing, because no Western country has done very well at that. Tracing would benefit from legal powers to examine banking and phone records without a warrant. What about migrants who illegally enter the country? Some will be infected, and all will have a reason to avoid the authorities.

          • I mean, you said it already; you shut down all unnecessary travel, and mandate testing and quarantine on arrival and exit for necessary travelers.

            • Craken says:

              I suspect that within a year or so there will be 2 categories of countries: those that extirpated the virus China-style and those that gained herd immunity at a catastrophic price. Neither category would have many active cases.

            • Pablo Stafforini says:

              Why is the cost of shutting down all unnecessary travel and testing necessary travelers lower than the cost of imposing no major restrictions and testing all travelers?

              • Pablo Stafforini says:

                Further to my previous comment, a Chinese firm has developed a test that can detect the COVID-19 virus in 15 minutes (as opposed to six hours). As far as I can tell, rapid testing makes strict border controls unnecessary: why ban all travel when you can quickly test every traveler?

  16. David Chamberlin says:

    What is being done?

    My wife is sick with a dry cough. 99% chance it’s flu. Very few cases in my neck of the woods. But what is the responsible thing to do? Get tested just in case you do have it you can self isolate yourself or do what they instruct to do.

    They don’t have the tests. They say come on down to the crowded hospital and see a doctor if she feels worse. That’s idiocy. That’s what they did in Wuhan. How did that work out.

    We need those tests and we need people to be able to take them at an outdoor drive through like they are doing in South Korea. Trump is fucking up, CDC is fucking up, and it is going to blow up just like it is in Italy and did in Wuhan.

    I’m disgusted, not worried about my wife, I’m pretty sure she is fine, just disgusted.

    • Space Ghost says:

      Why would she not self-isolate if it’s “just” the flu? How would your behavior change for a positive vs negative test for covid-19? Are her symptoms bad enough that she needs professional treatment?

      • David Chamberlin says:

        Of course she is staying home, she’s sick. She’s not very sick, and I am not very worried. What would she do if she tested positive? Probably self isolate, as instructed. I have kids living in the area, they could bring us what we need. And then there’s Amazon Prime. I can’t believe they told her to just walk into a crowded hospital and the doctor would see her. Just stupid.

      • gothamette says:

        I think Dave is saying that we are essentially being told to spread the virus.

        In a country like the United States, we should have drive-in testing sites, or maybe even mobile testing units to come to people’s homes.

        • David Chamberlin says:

          What I am worried about is not my wife or myself. We are OK. But our government has learned nothing from what went wrong and what went right in China and South Korea. When this hits hard it going to be handled completely wrong. Go to the crowded hospital and see a doctor without being tested if you have Covid19 symptoms. Absolutely idiotic.

  17. j says:

    “WHO Director-General reiterated that countries should not give up on stopping the outbreak now
    that WHO has characterized it as a pandemic. A shift from containment to mitigation would be wrong and dangerous. This is a controllable pandemic.” He seems to disagree with “flattening the curve” (mitigation) policy.

  18. tc says:

    Going by the news stories and Twitter, it seems that in many places it is still quite hard to get a Coronavirus test. However, according to Scott Gottlieb (former FDA commissioner and a guy who was right from the beginning), there is actually substantial testing capacity in the USA right now, enough to run 22k tests per day: https://twitter.com/ScottGottliebMD/status/1238219908527390723

    It seems that there’s obvious low-hanging fruit here: some sort of app that matches up demand for tests with excess capacity. Furthermore, we should be using all remaining testing capacity to run random tests on the population, especially people who travel a lot and meet a lot of people. NBA players, entertainers, politicians, airport workers…

    • gothamette says:

      Look, there is capacity but how do you GET the test?

      What do you do if you think you are infected?

      There are no protocols in place.

      If you think you’re infected, you are told to self-isolate. That’s it. Plus wash your hands.

  19. Agrifolia says:

    Zinc lozenges. That stuff works wonders against cold viruses, probably including coronaviruses, when used with the right timing.

    • John Massey says:

      For Covid- 19, the zinc needs to be taken with chloroquine to get the zinc into the cells. Actually, the Chinese have shown that hydroxychoroquine is better than chloroquine, and better tolerated by patients.

      • minosp says:

        My own experience is that the grocery store lozenges with only small amounts of zinc does the trick exceedingly well, at least against any of the various cold viruses I’ve been exposed to over the past decade. This is as a prophylactic or treatment at the very early stages of an infection, which is likely not what the choloroquine investigations were looking at.

        I suspect the mechanism is extracellular, possibly via loading the particles at the nasopharyngeal mucosa with zinc and rendering them noninfectious.

      • gothamette says:

        chloroquine

        Don’t you need a script for that?

      • David Chamberlin says:

        Right again. Zinc by itself won’t penetrate cell walls but with Hydroxychoroquine it can. Chloroquine has side effects.

      • gothamette says:

        @John, I know you don’t like Twitter but here’s one esp for you:

    • gcochran9 says:

      A good book, but a new version, written by somebody that understands natural selection, could be better.

    • minosp says:

      The intelligentsia is finally starting to notice how to properly employ zinc.

  20. j says:

    South Korean experts are recommending the use of hydroxychloroquine in combination with anti-HIV medication. HCQ is sold under the brand name Plaquenil, among others, and is used for the prevention and treatment of malaria.

  21. Peripatetic Commenter says:

    If we could find a way to embed the portion of the ACE2 receptor molecule that COVID-19 binds to in our mucus that might be a good first line of defense. That way we could reduce the number of COVID-19 virions getting to our cells.

    Or, perhaps create masks with the ACE2 receptor molecule embedded in them to take out lots of the little buggers.

  22. dearieme says:

    A former colleague of mine was made seriously ill by an anti-malarial: I think it was an injection she had before she flew to India. I don’t know it’s name. It couldn’t be Chloroquine or something closely related could it?

  23. Johnny C says:

    What’s the basis of the recent posts here claiming that this version of coronavirus is up to 40x more lethal than “normal flus”? I haven’t seen how anyone truly came to this conclusion, or if there is even enough time to, given the required data.

    • gcochran9 says:

      The fraction of people admitted with the flu that actually die is < 0.1%.

      In Italy, right now, the fraction of those admitted with coronavirus that actually die is 5.8% ( in a situation in which sufficient supportive care is not available)

      Can you do arithmetic?

      The fraction that are not immune to coronavirus is 100%. MAny people take the flu vaccine and it usually works to some extent – so many people are immune, and many more people have had flus in the past that were at least somewhat antigenically similar. So a lot of the population has some degree of immunity to influenza.

      If we do nothing, the limiting fraction ( at which coronavirus would stop spreading) is R0*( the unexposed fraction). Sine R0 is around 3, that limiting fraction is about 2/rds of the population.

      Hospital capacity would exhausted far before that point – way before. So the relevant IFR might be a couple of percent, if we assume a fair number of asymptomatic cases, but more like 5% if there are not a lot of asymptomatic cases. Multiple that by a couple of hundred million people. Can you multiply?

  24. Johnny C says:

    I can counter your “admission” illogic, but let’s go somewhere else more important: how long would you maximally shut down the economy to “save” however many people you claim to be saving? Doesn’t that also have a cost for all the other people’s health in the system for the next several years? So you are in charge, when do you call the restriction/regulation dogs off? Will Bill Gates be right at 6 weeks?

    I’m pretty sure South Korea can do math and they are much less spazzed out than you are, Gregory. Can you multiply the tenuous nature of the economy, markets, and banking systems? Hmm, I wonder which multiplication table is more important. That is indeed the question.

    I find these important questions, so I at least thank you for your response.

    • gcochran9 says:

      It is easy to have almost the same life expectancy as the US at considerably lower income levels, as can be seen by a cursory look at the World Almanac.

      For example:

      Life expectancy in the US: 78.7 per-capita GDP in the US: 59,500

      Life expectancy in Mexico: 77.12 per-capita GDP: 8900

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