First, listen to the experts. Here is who I have found helpful to follow:
Some people I follow and trust are (to name just a few): @cmyeaton @MarionKoopmans @JeremyKonyndyk @JeremyFarrar @mlipsitch @BogochIsaac @EckerleIsabella @aetiology @maiamajumder @angie_rasmussen And yes: @WHO @ECDC_EU @CDCgov
— Kai Kupferschmidt (@kakape) March 4, 2020
I’ve been trying to figure out what is going on and what the response actually will be. This has been an attempt to just make sense of what various experts are saying, and think about the implications. I know nothing about this beyond what I’ve learned in the last few weeks, like the rest of us.
Here is what I think is going on:
It’s tempting to ask, “how lethal is this virus?” It’s also tempting to summarize that lethality in a number. But the mortality rate of a virus is not some fixed fact about the virus. The reason why the usual flu isn’t so very lethal is because it’s seasonal, there are vaccines, we have experience treating it, and so on.
So this new virus has a mortality rate, and for vulnerable populations it does seem to be many times worse than the usual flu. But mortality is not simply about biology. And that’s where the real potential for crisis begins.
Because this virus is new to humanity and spreads so rapidly, dangerous cases can pile up very quickly. If hospitals are overwhelmed with cases and don’t have enough nurses, doctors, beds, masks, and so on, the virus suddenly becomes much deadlier. If you have a choice between everybody getting sick over the course of a month or spreading that out over many months — you would definitely want that second option. All things being equal, the mortality rate will be lower.
Not all things are equal, though. Stretching out the timing — dragging this whole thing out as long as humanly possible — also buys time for scientists and medical professionals to figure out how to treat the sick. It makes sure that doctors themselves aren’t all sick at once, and available to work. It gives the government time to fund mask manufacturers so supplies aren’t immediately depleted. And, of course, it gives researchers time to work on a vaccine.
When it comes to pandemics, slower is better.
A lot of what has been happening so far feels like an attempt to contain the disease. We’re used to a world where people are quarantined to keep the disease from spreading. For example, the WHO has been speaking about how it is important not to give up on containment of the virus as a goal:
“As long as you have these discrete outbreaks … there is the opportunity to control them — to get on top of these and contain them and prevent a lot of disease and ultimately death,” says Dr. Bruce Aylward, a senior adviser to the director general of the World Health Organization. “That’s the big message we saw in China — and one of the big surprises.”
Other experts, though, have been puzzled by why the WHO is talking like this. From their point of view, the opportunity for containment has long passed:
1/ I'm very worried that we don't have a clear strategy for #COVID19 response
We need to clearly define when the public health goal is containment-trying to keep the virus from circulating- and when the goal shifts to mitigation-working to reduce the peak impact of the outbreak
— Farzad Mostashari (@Farzad_MD) March 7, 2020
I've been trying to get clear in my head why @WHO is pushing containment of #Covid19 soooo hard, given nobody could do what China has done. I've come to the conclusion it's about slowing spread so health delivery doesn't collapse. You should read this thread. https://t.co/yCxrmwFryK
— Helen Branswell (@HelenBranswell) March 7, 2020
As best I can tell, containment was never really a serious possibility. It’s just that even a failed containment strategy gives a government a head start on slowing things down, which is the real public health goal.
What will that mean, in the months ahead?
It’s hard to know exactly, because we’re constantly learning more about the virus, the disease, and potential public responses to it. It was initially unclear whether kids were even getting sick and spreading the virus, since their symptoms have been so mild. My sense is that evidence is starting to come together that children do get infected with the disease. If their symptoms are more mild, does that mean that they infect others at lower rates? We don’t know this yet, and governments need to know this.
What I’m getting the sense of, though, is that schools won’t be closed in the initial stages of local epidemics — for now.
There are a good number of school closings, but they seem to be focused on wealthier schools or school districts that are more responsive to the needs and fears of parents. They also include colleges and universities where online learning is easier to put together.
Public schools, though, are a big deal to close. And even experts who are raising alarm bells are reminding people that shuttering schools isn’t necessarily the right response. There are confusing network effects of closing a school. If you close a school where kids are getting their meals, will that send more kids to an overburdened hospital? Will nurses have to stay home to take care of their children? Will kids gather outside of school anyway? (This was apparently something that happened during H1N1 closures.)
That said, school closures, even big public closures, are clearly happening across the world. Japan, Italy, Saudi Arabia, they’ve all closed all of their schools.
Based on what’s happening in Seattle, it seems to me that this is the escalation of responses we can expect:
- Early isolation – When the virus is new to a place, a school (or anyplace else) will shut down the moment someone gets tested positive. There’s still a chance at some kind of containment of the virus early on. This is when public health officials want to isolate and chase the cases.
- Individual caution – When the disease is plausibly in your neighborhood, it seems that public health officials then urge individuals to start changing their habits. Be on guard, they say. You may have this disease — don’t mess around, isolate yourself is you are feeling sick. Wash your hands seriously. Cut down on contact. Reasonably avoid crowds. On the margins, be more careful. And this has an impact.
- Easy shut downs – As cases pile up, places that can begin to shut down. Private schools or districts that aren’t responsible for providing a lot of social services begin to shut, when cases are a degree or two away. People are encouraged to work from home as much as possible. Big events are cancelled or postponed.
- Tougher shut downs – If things continue, then bans on gatherings above a certain size can be imposed.
And so on, and so on. And if a community starts approaching the capacity to handle cases, and there’s a risk of running out of healthcare resources…that’s when the serious moves are pulled out. And, as far as I can tell, that’s when large schools districts with lots of poverty will begin to close, for several weeks.
My sense is that various countries have been able to avoid these tougher shut downs, for now, by aggressively pursuing 1-3. Part of the work of 1-3 is extremely widespread testing for the virus, and the US has gotten a slow start on this despite adequate warning. (It doesn’t seem like this is entirely the fault of the White House, but it seems like they didn’t help things along at all. Here’s a piece about what we know about the testing rollout.) That’s somewhat scary, but my understanding is that testing is ramping up in the US. Hopefully we’ll be able to move smoothly on that front, from now on, but who knows.
All this, though, is just the first wave of the virus. Who knows, at this point, whether we’ll get any reduction in cases when the weather gets warmer. Even if it does, though, we’ll have to deal with all of this again in the fall. We can expect waves, though future waves will (hopefully) not be as severe. Anyone who already fell ill will have some immunity (as researchers have recently confirmed). And who knows, maybe we’ll know more about treating it. Hopefully we’ll have a better sense of what measures are effective by then at slowing its spread.
But we should expect a few waves, I think, over the next year or two. That’s my impression.