Imagined Futures Under COVID-19
What will future look like under COVID-19? For now, most of us are imagining a future defined by the following graph. By washing hands and avoiding crowds, we try to “flatten the curve”. We don’t contain the pandemic; we attempt to mitigate it.
Only one problem: this imagined future is not supported by real COVID-19 experiences of any country so far. Countries have either seen very large spikes with weak measures, or have suppressed the new cases to near zero with strong measures. To have a flattened curve as shown below, it requires a country to adopt just the right set of measures to effectively curb the spread, yet not enough to suppress it to near zero.
Worse, “flattening the curve” does not present a desirable future at all, even if it does happen. Due to its fragility as a strategy and undesirability as a future, “flattening the curve” is a wrong version of imagined future, leading all of us down a wrong path.
The graph below shows the real curves of various countries. These real curves pose another theory: a country either contains COVID-19, or it doesn’t. There are countries that see an exponential decline in the number of newly infected cases — South Korea and China may not have exactly seen zero increases (which will take global efforts), but their # of new cases have been reduced to and kept at very low, at double digit numbers. And there are countries that see an exponential increase in this number, including the United States and countries across Europe.
So far, no countries have shown a “flattened curve” — which means adding a significant number of cases one day, without exponentially more new cases during the following days. There has so far been no evidence of a middle ground between containment and all-out spread, one that has been imagined as “mitigation”.
Furthremore, if we consult US city curves in 1918 flu pandemic, the “flattened” phase is only a transitory stage between spike and suppression, or from suppression back to a repeated spike. A moderate outbreak that happens to be just within the healthcare system’s limits requires the virus to be transmitting at the just right pace, which has been historically much rarer than either a full outbreak or a near-zero suppression.
Credit: https://www.nytimes.com/interactive/2020/03/19/world/coronavirus-flatten-the-curve-countries.html; Graphs as of 3/19/2020. Many more countries’ curves can be found on this page.
The Unexamined Assumptions of Mitigation
Mitigation has not happened, because the conditions for mitigation are not socially sustainable. If we examine our scenarios seriously, it will be clear that the “mitigation” scenario — if actualized — is not at all desirable.
On March 17 2020, UK’s Chief Scientific Adviser explained the British strategy towards COVID-19: mitigation and herd immunity. This strategy was widely criticized, but not changed up to the time of writing (March 23 2020; some media reports mistook later government euphemism for a change). In the news conference, the scientific adviser lays out three assumptions for the mitigation strategy.
- “Impossibility of Containment”: The virus cannot be contained, and the entire population will inevitably be infected.
- “Relatively Low Costs of Mitigation”: The costs of mitigation will be bearable. It will be significantly less than the costs of containment.
- “Relatively High Costs of Containment”: The costs of containment virus, if it had to be, will be beyond imagination.
Unfortunately, the Chief Scientific Adviser did not lay out justifications for any of these three assumptions. The Chief Scientific Adviser, Sir Patrick Vallance, is an expert in vascular biology, not in public health or infectious diseases.
Based on consultation with several public health experts teaching or studying at leading research institutions, I reached the conclusion that these assumptions are based not on science, but on politics. Below, I analyze each of these three assumptions.
The “Impossibility of Containment” assumption is defeatism and flatly wrong. As shown by the real curves, at least several East and Southeast Asian societies — Singapore, Taiwan, South Korea, and mainland China — have all demonstrated successful containment of the virus, currently at close to zero new cases per day. If containment were impossible, how did these societies achieve it? Assuming the impossibility of containment really requires blind-folding one’s eyes to these Asian societies hit early by COVID-19.
The Undesirability of a Curve Flattened (Not Stopped)
What are the costs of mitigation? Will mitigation cost relatively less than other strategies? In my reading so far, the “Relatively Low Costs of Mitigation” assumption has not been checked, so I will tally the costs below.
Cost #1: 28 million (or so) direct casualties from COVID-19. Take the Marc Lipsitch assumption that 20–60% people will get it (let’s use 40% for a medium estimate), and the current mortality rate of 1% (a conservative estimate given the majority of world population live in undeveloped countries with inferior medical resources), then the medium # of deaths in this pandemic will be 0.4% of world population, or 28 million.
Cost #2: dysfunctional hospitals for many months, leading to indirect casualties. Given 1 out of 5 infected people need to be hospitalized, the hospitals worldwide is going to take care of 800 million coronavirus hospitalizations during one outbreak. This will squeeze hospital resources and limit capacities to treat other patients, thus increasing mortalities in the general population.
Cost #3: long-term health consequences in millions of survivors. The long-term consequences of infection are also currently unknown. However, since this virus is similar to SARS, it may be not unreasonable to take a page from known long-term consequences from that. It may include permanently damaged lungs, severe osteoporosis among young adults, either of which disable a person from most forms of work.
Cost #4: global economic recession. People easily recognize how extreme containment measures affect the economy, but underestimate how a “flattened curve” itself impacts the economy. Suppose we successfully flatten the curve to 12 months. In US, “flattening the curve” to a 12-month period means 300,000 new infections on average every day — about 70 times of the new cases added in US on 2020/3/22. During these 12 months, will people continue to go to restaurants, bookstores, and ice-cream shops when COVID-19 is still spreading? Some will, but many will not. The “flattening the curve” strategy is a perfect recipe for global recession.
Cost #5: social injustice. Among the direct and indirect casualties under the mitigation strategy, the senior citizens and the poor will take the hardest hit. During an extended period of migration and economic recession, the most vulnerable populations and societies will be hurt the most. The mitigation strategy has unintended but severe consequences for social justice.
Given all these costs, why do many among us advocate for mitigation? We do so because we see the unbearable cost of do-nothing, and also because we neglect the real possibility and necessity of containment.
The Unbearable Cost of All-out Pandemic
In recent turbulences of the financial markets, some people are starting to argue for a quick “getting-over”, namely giving up and letting an all-out pandemic happen. This is also wrong, because all the five costs above will be there during an all-out pandemic, only worse.
The direct casualties are going to be much higher, as many patients will have no chance to receive treatment. Hospitals will be punctured. Millions of survivors will be left with permanently damaged lungs and/or other organs. Recession will be inevitable following months of continuous tragedy and fear. The human conscious may never recover from a 21st century policy that deliberately put tens of millions to die, because they are deemed unworthy of saving.
The Only Real Option: Containment
Imagine this future. Hospitals are not over-run, restaurants and bookstores will re-open, far less than 28 million people will die from coronavirus, the economy will rebound in foreseeable future, and the weak and poor get reasonable protection against the pandemic.
This future is called containment. It has so far been hastily brushed off, due to its apparent impossibility. Let’s shelve our prejudice for a moment and ask: What made it impossible? If it is deemed far too costly, what are its costs?
If we take the East Asian experience seriously, then the answer is simple: Containment is possible, and it costs much less than mitigation or do-nothing. Containment costs these: masks, testing, and tracking, for everyone. No tens of millions let to die, and no many more months of closed businesses and empty streets.
The South Korean experience is a great example. Ask people to wear masks in busy streets and grocery shopping, so that asymptomatic transmission (an important contributor to the pandemic) could be curbed. Coordinate the supply chain to produce enough masks for everyone who needs them. Test and uarantine infected patients who do not need hospitalization, so that they do not have to infect others when they take the subway home. Use digital technology to trace and inform people who have come in close contact with the infected.
The problem is, do Asian experiences count? Are they valid experiences for European and American societies to borrow? Unfortunately, all of the world’s 50 public health schools are located in Europe and US. Not a single public health expert from Asia has been able to convey that experience to their global authority colleagues in the West. Even when public health experts in Asia ask world public health authorities to reconsider mask guidelines, their voices get ignored.
Courage Needed at Historical Moment
If you need one more reason to be convinced, consider this: the coronavirus, like the flu, may come back year after year. With a single-strand RNA, COVID-19 is prone to mutation. This means that no single vaccine can be made to contain it, and new vaccines may be always one step (meaning one year) later than some new coronavirus. We need a sustainable, global approach to deal with not just this coronavirus, but all future coronaviruses.
So far, our experiences around the world suggests flattening the curve may not work at all. Given the widespread asymptomatic transmission of the virus, half-hearted measures are likely to do too little to flatten the curve significantly. When you announce lockdown but do not really stop asymptomatic transmissions, the curve will still be going exponentially upwards. This is the experience of Italy, one likely to be replicated in US in weeks to come.
If responding to COVID-19 is like a war, then mitigation is the new pacification. We do not want all the hardships to defeat it, and we feel we are doing something by mitigating it. However, mitigating is giving in to the virus — literally giving in 7 billion pieces of human flesh to the virus to consume.
You may prefer political moderation, because it is realistic and you want to be realistic. But the virus knows no moderation. As the real country curves so far tell us — there is no middle ground for this virus. We, as a 7-billion race, either surrender to it or defeat it.
You may also be deterring to public health experts on our strategy. However, the expert community has taken diverse views on how to respond to COVID-19, as so much of the consequences go beyond any disciplinary expertise. Recently, a Harvard public health professor has also argued that mitigation is not enough. As this pandemic influences every one of us, it requires all of us to form an opinion and act. What pertains our public life is, after all, a political decision.
Certainly all historical experience confirms the truth — that man would not have attained the possible unless time and again he had reached out for the impossible.
— Max Weber
It is time to reach out for the impossible. Don’t flatten the curve. Stop it.