The Next Possible “Greatest Generation”
The economic devastation rendered by COVID-19 is driving the United States into an economic decline that could be worse than the Great Depression of the thirties. The economic consequences of COVID-19 would actually be much worse without the “social distancing,” closures and travel limitations. Aggressive action by Congress, the Federal Reserve and the Executive branch can turn this financial disaster around in a few months, but it will require bold and gargantuan courage by our leaders to do so. The CARE packages to date are survival help, but without bold action by lawmakers, the financial losses businesses and families will suffer in the coming months will have economic consequences for years to come. We need $6-7 Trillion in economic stimulus to avoid an economic collapse worse than the Great Depression of the thirties.
Our doctors and nurses and others working in the healthcare industry, grocery stores and pharmacies are modern heroes in an unexpected war against a difficult enemy. In the near future, they will have no choice, but follow the same rules that health-care workers are left with in conflict and disaster zones, having to ration care and services, as there may not be enough supplies, equipment, pharmaceuticals or even food. We have already had to shutter businesses, close school and limit the physical exposure each of us has to one another through physical distancing and “sheltering in place” at home.
On Dec 7, 1941 the United States suddenly found itself pulled into a World War. The country quickly united almost unanimously to fight the enemy. Political differences were set aside and the country, mired in the Great Depression, was suddenly catapulted into a huge, unified and mostly centrally controlled war effort. The national debt had grown to $42 billion from government efforts to assist individuals and businesses during the Great Depression, but this was not enough to reduce the 25% unemployment rate and many business bankruptcies. But the needs of the war effort ballooned the national debt to $269 billion (about $6 Trillion in today’s money) after 1944. It took 10 years to get the national debt down to pre-WWII levels using a much higher tax structure than we currently have, but during those 10 years we saw a huge economic boom. Most families were able to move into the middle class with only one breadwinner. There were still inequities, but as a whole, the lifestyle of most American families improved dramatically in the fifties and lead to the consumerism of the sixties and seventies that is the trademark of the American economy. Unfortunately, most wages did not keep up with the rapidly inflated cost of living during the eighties, so the American Dream cannot easily be attained by most young people today. It is especially difficult for the “Millennial Generation” with the high cost of housing and student debt.
The relatively small investment made by the federal government during the Great Depression kept many people employed and fed, but there were still many bankruptcies and foreclosures and at one point the unemployment rate reached 25%, and was still nearly 20% in 1938, when the federal government created the CCC and other programs to put young people to work. But after Pearl Harbor, both parties worked together to create huge federally financed projects and by 1944, the unemployment rate was nearly zero.
Can we avoid another Great Depression?
With businesses closed and many individuals furloughed, the economy is entering a deep recession and could easily go into a depression. This is already the “Worst slump since the 1930s.” The huge influx of capital into industries for WWII created many jobs, expanded manufacturing and other industries and not only allowed the USA to successfully defeat the human enemies attacking us and our allies, but reversed the economic disaster of the Great Depression and established the largest growth in the American Economy 1949-1962. Only the US federal government has the capacity to create the funds needed to avert economic collapse. A large investment, well managed, will not prevent the economic downturn from COVID-19, but it will reduce the impact of an all-out depression, to a brief recession.
The $2.2 trillion bill recently passed by Congress (Coronavirus, Aid, Relief, and Economic Security Act-CARES package 1) is not an economic stimulus, but a survival package that can cushion the fall of the economy, but will still leave millions of Americans destitute, unable to afford their housing and certainly not able to be consumers like they were in 2019. This was only a rescue package. We need a real economic stimulus. In addition to the impact on the US economy, this is a worldwide recession, far more so than the Great Depression of the thirties. Already household income in many parts of the developing world has declined by 75-80 percent. Our economy is tied closely to the rest of the world. The virus respects no borders, so even if we control it here, it can return easily, if not controlled all over the world. And the economic impact on other countries will have an impact on our economy.
Learning from the past
The errors committed in 1919 that allowed the 1918 Influenza pandemic to rebound are well known and need to be avoided. Let us learn a positive lesson from 1942 and through the war, when federal investment both helped to defeat an enemy, but also revived a moribund economy.
A vaccine against COVID-19 has been touted as the best way to end the “lockdown” that is impeding the economy, but realistically that is 2, 3, even 4 or more years down the road. There is a great deal that can be done now, that will get people back to work (but like during WWII-not necessarily at the same job) and avoid the economic destruction of so many suddenly falling into poverty.
Young people in 1942 joined the government effort to fight the enemy either by joining the military, (as my mother did) or working for companies specifically building what was needed for the war (as my father did). Everyone had to sacrifice due to rationing, as I often heard my grandmother explain (but not complain) about living with rationing and other restrictions. Young people in 1942 grew up quickly and had to forego much of their social life. The effort and sacrifice they made gave them the title, “The Greatest Generation.”
Those who were young in 1942 came together to serve our country in a great time of need. We need the help of our young people again and we need Congress to support them in their effort to combat the medical and economic effects of the disease COVID-19, caused by a virus: SARS-CoV-2.
The United States is faced suddenly with a new, vicious, invisible enemy. This time is different, as the whole world is facing the same enemy. All of humanity needs to unite in the fight against this common foe, a small speck of genetic material that has devastating consequences.
The United States has the world’s reserve currency. Our close allies are currently dependent on short-term loans from the Federal Reserve to support their central banks. Only the USA has the capacity to underwrite the huge effort needed to truly fight COVID-19 and simultaneously recover our economy and stimulate the economies of our closest trade partners, while concomitantly slowing the spread of the virus and the economic destruction in its wake, throughout the rest of the world.
Etiology-A Novel Virus
The first SARS-CoV-2 viruses reached the United States was on 19 Jan 2020, although it was some time before it was recognized. The disease had spread very rapidly in Hubei Province, China since their first documented case on 19 Nov 2019. Its virulence and contagion was not recognized until late December. In January Alex Greninger, an epidemiologist and viral expert, and eventually with the support of Keith Jerome, a virologist also at the University of Washington in Seattle started to develop large scale testing capacity in December 2019, but others felt the threat was minimal and tried to slow their efforts.
Efforts in other countries
Although the virus to date seems to have spread and been most deadly in Italy and Spain, the United States was not as prepared for this crisis as many other countries, which have been able to effectively limit the spread and slow the destruction: “flatten the curve.”
If one person infects on average three others, and they infect 9 and they infect 27 and they infect 81 and so on, the line plotting the number of infected individuals moves upward at an exponential rate until it finally reaches a peak when everyone is infected. If instead, over the same period of time one person only infects two, and they four, and they 16 and they 32, the curve has been “flattened” and is less steep. If each infected individual infects only one other person, the curve will be totally flat and if not every infected person infects someone, the curve will actually decline, and that is the goal.
Aggressive Response in South Korea
The first SARS-CoV-2 virus to spread in South Korea also arrived there on 19 Jan, but S. Korea still had their MERS emergency response team, that had been set up in 2013 (to fight the MERS epidemic, that was in danger of becoming a pandemic). They quickly obtained a large supply of test kits from Germany and started manufacturing their own tests with support from the German manufacturer. A large cadre of public health technicians aggressively tracked down, not only the contacts of each positive case, but the contacts of the contacts. Isolation was quickly enforced. Cell phone data and credit card data was utilized to trace every step each potential case had made in the last 72 hours and even brief contacts, such as cashiers were isolated for the 8-10 hours it took to get the test results. If the test was negative, a text message was sent to the individual that they could return to normal activities, but if the test was positive, a public health technician went to that individual’s home to establish and enforce a 14 day quarantine. As of 4 May, S. Korea has gone 4 days with no new cases.
German medical producers had recognized early on that the virus in Wuhan, China would spread and developed an accurate test platform for the virus and began a massive manufacturing process so they could be prepared to do broad based testing and supply or support testing in the rest of Europe and even Iran, when cases began to spread there. Germany started repeat testing to determine the incubation period of the virus and to detect, as much as possible, the asymptomatic carrier rate. Germans were among the WHO team (World Health Organization which collaborates with the United Nations) that went to China in December 2019 at the first sign of the novel coronavirus infection to analyze the viral genome and study the course of the disease, COVID-19 and evaluate treatment strategies.
German and Scandinavian skiers returning from Austria unwittingly carried the virus to several cities. A businessman from Wuhan later tested positive after visiting Munich. The virus quickly spread throughout the country. Germany has more hospital beds, ICU beds and ventilators per capita than most other countries, including the US, so their health care system is not overwhelmed and they are taking patients from other countries. Yet the number of positive tests in Germany is very high, as a very large percentage of the population is being tested. (Likewise, the number of negative tests is also huge, as the virus has only infected a small percentage of the population, mostly younger and middle aged individuals, as opposed to Italy). Still the virus spread much faster than in Korea and was much more widespread from the start, so Germany has had to close its schools, shutter its factories and close all but essential shops and have almost all Germans stay at home. The death rate in Germany remains very low by comparison, because so many without symptoms are being tested. However, it is rising now, as elderly, who were hospitalized two weeks ago, are now beginning to die.
Germany has excellent healthcare and public health resources and the largest testing capacity for this new virus of any country in the world. However, cases were quickly found in several cities at once and the experts gathered together and determined that doing testing, isolation and contact tracing, as was being done in South Korea, Taiwan and Singapore was not enough. New cases were being found in many places every day and so tracking down all these cases would not be able to be done quickly enough to slow the spread of COVID-19. So Angela Merkel advised the leaders of the 16 German states to close nonessential businesses, schools, day care centers and limit travel. Each state set slightly different restrictions and these were modified based on the rate of infection by each county individually. Restrictions were not identical in each state and were instituted at different rates. One state with no cases did not have to institute strong restrictions as had to be done in the major cities of Berlin, Hamburg and Dusseldorf. One state tried to delay some of the restrictions due to the expected economic impact. Unfortunately, the virus spread quickly in Munich and stricter restrictions had to be imposed. The leaders later admitted that the restrictions should have been imposed earlier. Now as efforts to relax the restrictions are being considered, Bavaria, the last state to impose “stay at home” rules, will be the last state to allow the implementation of the 12 steps the federal government has outlined for reopening schools and businesses.
Restrictions, often to stay at home completely, have been imposed in many countries to slow down the spread of the virus. “Social distancing” (actually physical distancing, as we can still be socially in touch) works to significantly slow down the spread of the virus. However, restrictions on businesses have economic consequences and restrictions on schools will certainly have academic consequences. Even so, the economic consequences of letting the virus spread through a population unimpeded is very much worse.
Why restrictions on human interactions saves lives, and actually can save money
When the virus spreads rapidly and it is not possible to test and track every contact, then political leaders (hopefully with the input from scientists) are forced to decide if the risk of spreading is severe enough to place limitations on the interactions of the population. Initial reports showed that COVID-19 is about ten times more deadly than influenza during the normal flu season and possibly more devastating than the 1918/1919 influenza pandemic. Later reports indicate that there are many who only contract a mild case of illness and some may never have any symptoms, despite being infected. So the death rate may not be ten times higher, but the infectivity (the ability of one person to infect others) of this virus, SARS-CoV-2, is huge, so the number of deaths, if allowed to spread widely would be huge. Furthermore, people do not die quickly, but can be ill for weeks. The average person who eventually dies from COVID-19 spends 3 weeks in the hospital and 14 days on a ventilator. If the virus were allowed to spread unchecked, the health care system of even Germany (which has more ICU beds and ventilators per capita than any other country) would be overwhelmed. With hospitals full with COVID-19, many people would die from otherwise treatable illnesses and accidents, including heart attacks, strokes, GI bleeds, diabetic complications and motor vehicle accidents; people who otherwise could have been successfully treated. Recently a New York City ambulance had to contact 80 different hospitals before it could find one with a bed for a critical patient. Also of concern are recent reports showing that those who do survive a serious illness from COVID-19 have permanent damage in other organs, especially the heart, liver, kidneys and even the brain.
If this novel coronavirus were allowed to follow its natural course in just the USA, it would spread over the country in a matter of months and nearly everyone would be exposed. If half the population contracted the illness, and the death rate could be kept below 2.5%, that would still be over 4 million direct deaths, but if the virus were allowed to spread rampantly, the death rate from the virus would be much higher, because it would not be possible to provide the optimum care for every patient and many health care providers would be too ill to work. Also, many individuals with other illnesses and accidents would not be cared for in the usual manner and the overall death rate could be over 10 million. Plus at least that many individuals permanently disabled, even though they did not die. The economist Anna Sherbina estimated that the cost of caring for all those who became seriously ill with COVID-19, if the virus were allowed to go through the population unchecked would be $1.2 trillion in direct costs and $13.2 trillion in lost productivity from workers being home ill, dying, or too disabled to return to work.
Some drastic measures were necessary, as the US cannot afford a $13.2 trillion hit to the economy and no one can accept 10 million extra deaths in a single year. The degree to which the virus has affected each community varies across the country, but each governor has put at least some restrictions on human to human interaction and in many states this has involved closing schools, cancelling events and shutting down or limiting all non-essential businesses.
As of 27 Apr 2020, the official death toll in the US for COVID-19, is 55,637, but like Italy, lack of testing means many have died of this disease and not been included in the figures due to lack of testing capacity. When Yale School of Public Health analyzed data from the National Center for Health Statistics it showed that there were an additional 15,400 deaths in March 2020 beyond those during the same month in several previous years, beyond the COVID-19 deaths. There were significant less deaths from homicide and motor vehicle accidents, so the total excess deaths beyond the COVID-19 deaths in March could have been nearly 20,000. Many of these would be individuals who died before testing was available, those who died at home without being tested and those who died from other causes because they could not get medical care in time, or did not call 911 soon enough (EMT’s in New York and New Jersey report a 10-15 fold increase in the number of people dying of heart attacks before they could get to an ER, or be treated in a crowded ER).
R0 (pronounce R naught) is a figure used by epidemiologists to explain the infectivity of viruses or bacteria or other organisms causing infections that can be transmitted from one human to another. An R0 of 1.0 means under the constraints given, each infected person will infect on average one other individual and the amount of infection in the population being studied will be constant. Many viruses that cause the common cold (including some coronaviruses that have been circulating for centuries among humans) have an R0 of about 1.0. Now in a day care center, the R0 is closer to 3.0 among the four year olds with a cold virus, but 0.3 among the workers. The four year olds mostly do not have immunity to the virus, are constantly touching each other, sharing toys and putting their hands on their faces and in their mouths. The care givers are mostly already immune and are much more fastidious in their hygiene. An R0 below 1.0 means that each infected person will not even infect one other person, so the contagion fades away, as usually happens with seasonal viruses at the end of the season.
SARS-CoV-2 had an initial R0 of 3.8 in Italy. Venice and Milan were initially hit and these are compact big cities with large populations, including many elderly and many small apartments with three generations living together. This is a very contagious virus and any infection with an R0 over 3.0 is considered explosively contagious. By comparison, though, one of the most infectious viruses is measles with an R0 over 18, and the R0 for the influenza of the winter of 2019 was 1.6.
Much of the world has been placed under restrictions of travel, movement and person to person interaction. This has slowed the spread of the virus, allowing time to develop treatments, build up the healthcare systems and possibly develop a vaccine. It has made us much more aware of how vulnerable we all are to an invisible invader. The answer to the first question is almost surely no. The Covid-19 pandemic is going to be one of those dichotomous events that divide life into before and after. We live through them, learn from them, and adjust. Think about how casual airport security was before 9/11 . . . or how simple it was to draw blood or start an intravenous line before HIV.
How do we come out of physical distancing restrictions and closures?
South Korea started with a very robust public health emergency system that had been established after the MERS crisis in 2013 and has had yearly increases in funding to maintain its efficiency and ability to respond rapidly. South Korea quickly obtained permits from the German manufacturer to produce its own testing kits and rapidly deployed them. This allowed S. Korea to quickly isolate and quarantine all cases and contacts. Taiwan and to some extend Hong Kong and Singapore have followed a similar model. Large scale limitations on businesses, schools and public transportation were not instituted. A culture of wearing face masks and often rubber gloves in public already existed. Frequent cleaning of shops, sidewalks, busses, trains and other places where people have to touch already was the standard.
Without resources already in place, the US, UK and even Germany and most of Europe have had to impose severe restrictions on businesses, close schools, eliminate public transportation and often require citizens to “shelter in place.” Once the supplies and public health staffing can be assured, the next step is called mitigation, which is what S. Korea was able to implement as the initial step.
Keeping scientific evidence as the foundation of decisions
Germany is working hard to develop a plan to gradually loosen restrictions, as the economic hardship is staggering. Germany is now, like the rest of the world, in a recession. A huge economic stimulus package is being developed, but currently funds and regulations are in place to temporarily eliminate rent payments, defer loan payments and assure the citizens are safe physically and financially. Germany is one of the largest exporters in the world and as the virus spreads around the world, it will be financially affected for years to come. The German economic relief package just passed represents 15% of GDP.
In just a few weeks the US has gone from having one of the lowest unemployment rates in history to having over 30 million laid off. $2 trillion (only 10% 0f GDP) has been authorized to prevent bankruptcies, augment unemployment, supplement rents and mortgages and keep families from financial collapse, while supplementing hospitals, whose incomes are drastically declining and supporting the health care services, needed to deal with this pandemic. Many companies are converting their production to meet the need for personal protective equipment, ventilators and other essential items needed at this moment of crisis.
Iceland was able to identify that the virus had spread to their isolated island from natives returning from ski holidays in Austria, on 28Feb, a week earlier than Germany identified its first case. Rapid testing of nearly 10% of the population and the ceasing of international travel made it possible to quickly identify all cases and test their contacts. The broad testing showed that nearly half of all positive cases had no symptoms. Minimal restrictions were needed and on 22 Apr the last new case was identified. They suffered only 10 deaths.
While in New Zealand a very strict restriction on commerce and schools was quickly implemented and all international travel stopped. They also were able to track all cases and identified the last case 26 Apr, declaring victory over the virus. All businesses and schools can now reopen and there will be no restrictions on public gatherings, although it might be sometime before they open to international travel. Although they had much fewer total cases than Iceland, they had 19 fatalities.
Taiwan instituted aggressive testing, tracking and quarantine resulting in only 429 cases, another island nation, but Hong Kong only mildly isolated from the rest of China and with busy international travel and trade has as of 27 Apr only 1037 cases and 4 fatalities.
Coming out of isolation and economic restrictions
The virus has taken longer to spread through the much larger USA and the US was slower to respond and has fewer resources than Germany. Germany has not yet developed a time frame for loosening the restrictions, nor given a time frame for the implementation of the proposed 12 step plan to return the country and the economy to normal. Furthermore, this plan will be modified and need the approval of the public health experts, who are developing models to determine how the virus will spread or be contained by the changing of regulations at each of the steps.
A vaccine or medical treatment against COVID-19 is still a very long way in the future. We must maximize non-medical treatments that can help combat the spread of disease now. The most immediate effective treatment is curtailing as much interaction between people as possible. The next step, that will allow a loosening of restrictions, is finding everyone who is infected and isolating them until they are well. This means testing on a very large scale. As of today (23 Apr 2020) less than 1.4% of those living in America have been tested. The best public health experts feel that 10% of the population should be tested every two weeks. Germany has set a goal of testing over 45,000 people per day (0.7% of the entire population every 2 weeks, the equivalent of 185,000 tests per day, 7 days a week, in the US-currently at most 100,000 per day). Ideally, public health officials feel there needs to be enough widespread testing that less than 10% are coming back positive. Currently in the US it is over 18%.
German experts feel that interpersonal restrictions need to be in place until R0 is below 0.5. When the virus first arrived in Germany and before any restrictions were in place, R0 was 2.8 (much lower than the rest of Europe) and restrictions quickly dropped it to 1.0 on 22 March. Angela Merkel stated that restrictions could not be lightened until the rate of doubling of the number of infected individuals was longer than 10 days. It was initially 2 days. An R0 of 1.3 is a doubling every 11 days. On 9 April Germany was down to an R0 of 0.9, so they are expected to be close to 0.5 by 5 May and can then move to step 3 of their 12 steps to being fully open. (However, loosening of regulations will be up to each state separately, and they will do that in each individual county separately based on the R0 of each county and its adjacent counties (Kreis).
Loosening restrictions before adequate testing and contact tracing can be dangerous. Hokkaido, Japan felt that with much of the country shut down and travel restricted, their isolated community could be allowed to get back to a semblance of the pre-COVID-19 commerce. Unfortunately, their limited testing did not reveal how widespread the virus already was in the community. The number of cases quickly rebounded and they not only did not have adequate testing capacity to test the symptomatic patients, but they lacked the resources to identify the contacts of those who did test positive and identify and isolate those asymptomatic individuals who were spreading the virus. The only recourse was to go back into a tight lockdown.
Adequate testing to track the virus is essential. If 90% or the tests being done are negative and 10% are positive, then the WHO feels enough testing is being done. German experts feel that is still inadequate. If more than 10% of the tests are positive, then too many cases are being missed. In S. Korea currently, only 3% of tests are coming back positive, so they are testing very widely. Whereas in Massachusetts recently, 31% of tests were positive, so probably less than a third of actual cases were being found. New York has had similar results and antibody testing of people at random showed that 2/3 to ¾ of the cases were being missed. Ohio is getting closer with 14% positive. Obviously much more testing capacity is needed before we can move from a “lockdown” restriction to a mitigation policy.
How much testing is needed? First we have to keep separated so the virus cannot spread. When there is only one new case each day for every 1 million individuals, then we can relax restrictions, because we should be able to test adequately to trace all contacts of that individual. Other studies indicate that at least 1% of the population needs to be tested every day until no new cases are found for at least 14 days.
Therefore before loosening the restrictions on our interactions, in order to prevent the death and debilitation caused by the virus and the consequent economic cost of an overwhelmed healthcare system, it is important to do adequate testing to determine that the ongoing rate of new infections is low, that enough individuals can be tested to determine and isolate any new pockets of infection that develop, that the healthcare system has the capacity to handle a resurgence, that enough personal protective equipment is available to everyone; and most importantly, that there is a well-organized, well-trained team of public health workers to test the population broadly, trace all contacts of positive tests, and isolate those who are infected to immediately stop the spread.
In order to safely protect the population and simultaneously open the economy, the Federal government must fund and secure adequate testing capacity, personal protective equipment and public health workers to track all contacts of anyone testing positive. That means we must hire and train at least 300 public health workers for every million people-or about 100,000 additional public health workers for the entire US.
What about antibody testing?
A safe and widely available vaccine against SARS-CoV-2 would be the ideal solution to end the need to keep everyone physically distanced and relatively isolated. However, the best prognostications are 18 months to develop, test and produce such a vaccine, more realistic is 24-30 months, if even then. No vaccine has ever been able to be produced against a coronavirus and work has been ongoing for over 30 years. Four common cold viruses, SARS and MERS are coronaviruses. Some new techniques are being developed using genetic modification, but they have yet to be tested on humans. An alternative solution needs to be found to allow safe loosening of current restrictions on our activities and the economy.
The problem with antibody testing is that no sufficiently reliable test is available anywhere, and the rapid tests that would make antibody testing feasible are even less reliable than the tests in dedicated reference laboratories. The actual value of the antibody titer (amount of antibodies detected in the blood) that infers immunity has not been determined and the body’s production of antibodies seems to take 1-2 months after the initial infection. We also do not know how long an individual will remain immune to this specific virus. Experience with other coronaviruses would indicate a year or two at most.
Even the best antibody test is not 100% accurate. Direct PCR tests for the virus itself are not 100% accurate, but they are close. If a viral test is being used that is 99% accurate and 1000 people are tested in a given community, and 50 people actually are infected and shedding the virus, then 49 people will have a positive test for the virus and really are shedding the virus (true positive) and 1 person will be shedding the virus, but could come back with a negative test, because it was not collected correctly, or processed correctly (false negative). 941 people will have a negative result, who are not shedding the virus (true negative), but 9 people will have a positive test, when they are not actually shedding the virus, due to cross contamination or other laboratory errors (false positive). So 9 people will have to be isolated for 14 days who didn’t really need to be, but most of us would agree that that is a small price to pay for protecting the public. If enough tests were available, all individuals with a positive test could be retested the next day and most of the false positives would be negative on retesting, but it is unlikely a true positive would be negative on the second test. That is because the sensitivity of the PCR test is nearly 99.9%, so rarely is a true positive missed. However, the specificity of the test is very operator dependent. Most labs have 97-98% specificity, so false negatives are 2-3% of those who actually have the virus. Therefore if a person has a fever or cough, and they have a negative test, repeat testing is indicated.
The equation changes considerably when testing for antibodies. Now we are not testing those who are at risk (have symptoms or known exposure), but we are testing for past exposure to the virus. If a specific individual had symptoms, or prolonged exposure to the virus, then the probability that they have developed antibodies is high. Most antibody tests have a sensitivity of 97% or better. So if the test comes back positive in the face of likely exposure or infection, then it is unlikely to be a false positive (although not impossible). However, if we are testing a large population to determine how widely the virus had spread in that population in the past, when we did not have adequate viral testing, then we will have less reliable numbers, if the total number of the population that actually contracted the virus is small.
Let us suppose that we want to test a community of 10,000 people and 5% of them have actually gotten the virus and recovered, or were exposed to a household member who was ill and although they did not get ill themselves, they developed antibodies against the virus. We should get 500 positive tests and 9500 negative tests. Our antibody test has 97% sensitivity, so we get 485 true positive tests and 15 false negative tests, however, not everyone actually develops antibodies, and so we probably will only get 475 true positives, 15 false negatives and 10 true negatives among those who had the virus. What about the 9500 that are true negatives? The test has 95% specificity, so we get 9310 true negatives. We also get 190 false positive tests. How do we separate the 190 false positives from the 485 true positives? We have to tests all 675 positives again in a couple of weeks.
However, if our purpose of doing antibody testing was to determine the number of people in the community who had been exposed before we could adequately test for the virus directly. If we already suspected that only 5% of the population had been exposed, we would have anticipated 190 false positives and the testing proves that our supposition of 5% was correct. If we had gotten 800, or 1000 positive results, then we would be able to calculate that 6% or 8.5% of the population had been exposed. If only 350 tests came back positive, then we would know that about 3.5% was the exposure rate. In that case, there would have been 350 true positives, but only 305-312 would have positive test results, and of the 9650 that should have had a negative test result, there would be 483 false positives. So when the incidence of the disease is low, the accuracy of a positive test can be very low. This is called positive predictive value of a test: true positives/all positives. In this last case 312/(312+483) = 39 %.
So antibody testing can be done for epidemiologic studies, but are not good at telling if a specific individual is truly immune. So they cannot be used to issue “Immune Passports” allowing an individual with a positive test to then stop taking any precautions.
What about “Herd Immunity?”
The concept applies well to a disease that gives long-term immunity, such as measles. If we are old enough to have had measles or chickenpox, our body developed lifetime immunity. With vaccines, it takes three inoculations to develop long-term immunity. If 85-90% of a grade school has been vaccinated, then it will be very hard for the disease to spread (although the ability of measles to be contagious is worse than COVID-19). This is called “herd immunity.” It has been speculated (even by me six weeks ago), that since most people infected with SARS-CoV-2 do not get that ill, that allowing the virus to spread among young, healthy individuals would induce antibodies and if 80% of the young population had antibodies, it would be difficult to spread (R0 would be less than 0.5).
Unfortunately, the potential of even relatively young individuals to get an overwhelming infection and either die or be disabled for months or years is too high to risk that. Furthermore, we do not know how good the immunity is after recovering from COVID-19, nor how long it will last. There are reports of individuals getting the infection twice, although there have not been any good documentation of this.
The idea of isolating only elderly and vulnerable citizens in the UK was considered and quickly abandoned as medical professionals calculated that even these young individuals would quickly overwhelm the National Health System. One of its principal advocates initially, Boris Johnson, found out how serious COVID-19 really is.
Sweden thought that with limited exposure to the virus, it might work there. Yet the number of individuals who have developed immunity is unknown. The initial efforts show it is not working. Sweden’s COVID-19 fatality rate of 156.5 per million inhabitants compares with its neighbors Norway (28.4) and Finland (17.7). For comparison, Australia (2.8) and New Zealand (2.7) have strictly curtailed travel as well as limiting commercial activity and other social interaction with physical distancing.
South Africa is a developing country with much poverty and limited medical resources, although far more than any other sub-Saharan Country. They have had 4220 confirmed cases and 79 deaths, the most of any African nation. Some of their cities are very crowded, but they have done an amazing job of limiting the spread of the virus, because they were well prepared. The first case there was on 5 March and it spread exponentially as it has in the US and UK. But on 27 March the borders were closed and the country went into a lockdown. More importantly, South Africa had 28,000 trained public health workers to track TB and HIV. They went out to the poor crowded communities and did wide testing and very meticulous tracing of contacts. These public health workers knew how to work with each of the various communities, how to gain trust and get people to agree to be tested and then visited back daily to ensure that those in isolation were compliant.
Is there not a medication that could cure COVID-19?
Short of a vaccine, some kind of medical therapy that could be widely used and prevent complications from COVID-19 could allow us to mostly return to normal. Pharmaceutical intervention is being investigated by many major researchers all over the world. Several antiviral drugs are being investigated that could prevent the virus from binding to the cells in the respiratory tract, or prevent the virus from replicating once inside a cell. Many studies are ongoing, but to date no drug that is currently available such as hydroxychloroquine and favipiravir; and including still experimental drugs like remdesivir and ivermectin have shown any benefit.
This means developing a totally new drug, as this virus is not acting like HIV or influenza for which we do have pharmaceutical agents. Most studies use hospitalized individuals, especially those already critical. It is easy to get permission to test an experimental drug on someone who may have no other hope. However, just treating the worst cases does not tell us if the drug might be more effective if given earlier. As newer drugs become available, particularly those that prevent the virus from binding to our cells in the first place, formal studies will be needed on people early in the infection, even those with no symptoms and might even need to be tested on individuals who are still naïve to SARS-CoV-2 and then exposing them, to see if the drug prevents infection. Such clinical trials have to be large and very carefully controlled, especially if the novel agent is to be given to thousands of otherwise healthy individuals and then exposing them to a potentially deadly virus. It will require months of research by the best scientists, initial tests on animals, then tests on a few humans, before it can be tried in a large formal study. Then it will require approval of the FDA or the accrediting body of other countries before it can be utilized by the population at large. This is still at least two years off, probably more, as a lot of research has already been done on SARS and MERS and no agent has been found.
What about Convalescent Serum therapy?
Although the antibody response to an infection with COVID-19 is highly variable, with some individuals producing little if any antibodies and others taking a month or two to develop significant antibodies, many individuals, especially younger and otherwise healthy individuals develop very large amount of antibodies very rapidly. Blood can be taken from such a person and the plasma separated and the red cells put back into the donor. The plasma is then processed and purified after testing to be sure the plasma does not contain anything that would harm a recipient. The part of the plasma that contains most of the antibodies are then isolated and this “immune globulin” can then be injected into an individual suffering from COVID-19. In theory the intravenous injection of immune globulin (IVIG) containing a high concentration of antibodies specific against this virus will fight the COVID-19 infection giving the patient’s own immune system a chance to win the battle.
This convalescent serum has been used successfully against SARS and was used a few times in China against COVID-19. Anecdotal reports indicate that it was successful. It has been tried in the US and Europe with mild success. The problem is finding the donors, and then if the plasma is to be processed quickly, it must be of a compatible blood type with the patient. Since this is in limited supply and there are limited centers currently available to extract convalescent serum, it is being primarily used on the most severe cases. However, the most severe cases are those who are suffering a cytokine storm. The immune system of the patient is damaging the lungs of the patient as it tries to fight the infection. For these patients additional antibodies might fight the infection, but cannot slow the cytokine storm or repair the damage done to the lung tissue by the patient’s own cytokines. For convalescent serum to be successful, it must be administered early in the infection.
Finding the donors who are eligible to donate and harvesting serum from thousands of people who have successfully recovered from COVID-19, processing the serum and then getting it to the specific patients who will benefit the most, is a Herculean task. It is worth pursuing, but is not going to be the answer to the pandemic that is currently raging across the world.
When could we expect a vaccine?
A vaccine against this virus would be ideal. A safe vaccine could be administered all over the world and if it were effective, it would eliminate the ability of the virus to spread and it would go extinct, as the original SARS virus has become, although that was because SARS was less contagious and more easily isolated. Worldwide vaccination has eliminated small pox and we were close to eliminating polio when the COVID-19 pandemic interrupted the final push to find the last cases. 2019 did see only 95 cases of polio, a disease that infected 400,000 children just forty years ago.
Since each individual responds differently to infection with COVID-19, we do not know if most or even a significant minority of individuals will produce antibodies against SARS-CoV-2 after being inoculated with a vaccine. Coronavirus similar to this one have been circulating among humans for centuries. Active efforts to find a vaccine have been tried for over fifty years. Efforts were intensified in laboratories all over the world with the 20054 SARS epidemic.
For some reason, not yet elucidated, the COVID-19 patient develops a low lymphocyte count. It is lymphocytes that produce the antibodies that can fight an infection and it is these same lymphocytes that need to respond to a vaccine in order to make the vaccinated person immune to infection if they inhale droplets containing SARS-CoV-2. This complicates the development of a vaccine. Convalescent serum from previously infected individuals will totally neutralize the SARS-C0V-2 virus in a laboratory environment called in vitro plaque assay, similar to studies done with SARS-CoV (the virus that caused SARS), but a vaccine that was developed did not induce an immune response in the individuals tested. Coronaviruses have a unique capacity to evade the immune system until they have replicated quite widely in the host.
There are six different types of vaccines that can be developed, including ones using recombinant protein genetic modification of the virus. The methods that are easy to develop and produce, such as DNA platform, do not seem to induce an immune response in the recipient. Adjuvant vaccines are usually the safest and are in preclinical trials, but may be very costly to produce. Live attenuated virus has been used in other classes of viral vaccines, but can have serious adverse side-effects and may not be safe for those patients most at risk of dying form COVID-19.
Reality is not like the movies (finding a vaccine in days in “Contagion”).
Finding a safe, successful vaccine is a daunting task. Many research scientists are working on it, but it probably will take a year of two, maybe longer to find a vaccine; and another year after that before it will be widely available. This is an effort that requires more work than the Manhattan Project of WWII. All the major governments of the world should collaborate and finance a “Manhattan-like Project for COVID-19.” All of the G-20 should collaborate and financially support this essential project, including the United States of America.
Viruses are made up of only a small amount of genetic material and in the case of coronaviruses, the genetic material is RNA. RNA is relatively unstable, unlike DNA of the chickenpox virus that has remained unchanged for probably centuries. The influenza virus mutates significantly every year, so whereas a varicella (chickenpox) vaccine is identical for each dose and after 2-3 doses induces immunity for most of one’s life, influenza vaccines have to be modified every year. Coronaviruses, and SARS-CoV-2 in particular, do not seem to mutate very much and the genetic drift is minimal. In fact the earliest SARS-CoV-2 viral genomes studied and the latest have only 10 nucleotide differences and these do not seem to affect the virulence or transmissibility. The natural selection pressure on viruses that cause disease is for changes to make the virus more contagious, so it infects more people, but usually less virulent, as a virus will spread more easily if the host is up and walking around than if the host dies quickly.
Coronaviruses 229E, NL63, OC43, and HKU1cause the common cold and probably transitioned from some animal to humans 500-1000 years ago or more. They are highly contagious; yet do not make a person very ill. Eventually SARS-CoV-2 will mutate to something similar, but it looks like it will take decades, even centuries to get to that point.
Finding a vaccine or medical treatment for COVID-19 is not going to happen soon. Letting the virus have unlimited access to humanity will cause catastrophic devastation and economic collapse. Once this virus starts rapidly spreading in developing countries, the poverty and mayhem that will result will further strain the fragile world economy that at this point is in free fall.
There is not going to be an easy medical solution or vaccine in the near future. We are in this for the long haul.
Yet leaving the economy in lockdown for the indefinite future will create a calamity that is worse than the Great Depression.
There is not likely to be a vaccine for years, despite the optimistic statements of many politicians. A treatment for the virus, or better yet a preventative medication, is probably also not forthcoming in the next few years. Therefore, we must have a Plan B.
A Wartime Response
Restrictions on normal activities needed to be put in place, but they cannot remain in place for a year or two. Germany can show us how and guide us as to when to loosen restrictions and S. Korea has set an example of what we need to move from containment to mitigation. But we need better and faster relief and the US is able to draw on financial resources not available to other countries.
Why the free market alone cannot restore the economy
The voluntary efforts by fabrication factories, the hard work by grocery stores and pharmacies to remain open and stocked (including the supply chain and logistics) and the $2 trillion economic survival package are helping, but it is not enough. The supply of essential goods, especially medical personal protective equipment and essential pharmaceuticals is inadequate; the number of health care workers, public health workers and workers in essential factories, and agriculture is hugely inadequate. The chemicals needed to manufacture medications and test reagents come from other countries and the supply chain has collapsed as worldwide demand for these basic essential ingredients has skyrocketed.
It does not make sense for different government agencies to be competing for the same limited supplies. Centralized distribution is needed as well as price controls.
This is a war!
Projections of the toll if no restrictions were put in place regarding work, school and other activities that bring Americans physically together is 2,000,000 deaths and $13,000,000,000 in economic costs and losses from decreased productivity of those who are ill or die.
During WWII the American people accepted rationing, price controls and government mandates as to what was produced in factories and even agriculture. Subsidies kept most factories and farmers functioning. A huge amount of research was done, including the Manhattan Project. The world needs a Manhattan-like Project now to develop vaccines and treatments for COVID-19.
During WWII the US Federal government accepted a huge increase in the national debt, as funds were needed to keep the country on a war footing. THIS IS WAR! The country needs to be on a war footing and only the federal government has the capability to underwrite the effort.
The economic cost of not restricting normal activities is proposed to be $13 trillion. The economic cost of a year of full restrictions has been estimated at $10 trillion. So the economic cost of a diminished economy is huge and only a few months of restrictions will have years of ramifications, but the economic cost and lives lost and caring for the ill, if not restricting activity is worse.
Based on the above numbers, it would therefore not be unreasonable for the US to spend an additional $7-8 trillion to support the economy and fight the virus causing COVID-19.
Rebuilding the economy and preventing the next pandemic impact on it
Initially large construction projects could be undertaken. Road building and certain “green” projects can be done with workers remaining at least six feet apart. However, what we need most urgently are factories and other fabrication centers that are large enough to allow workers to be productive while remaining 6 feet apart, or if necessary to be closer, work with adequate directed ventilation so that there is minimal chance of spreading virus particles.
Many fabrication centers, especially those producing small products are in small buildings in urban areas. Large parts of rural America is filled with dwindling small cities and towns that have space that would easily allow for the construction of fabrication facilities with adequate space for workers to work in this new environment. It is also easier in rural areas to go walking, jogging, biking, etc. and easily still maintain a safe distance from all others. It will also be necessary to construct electrical grid and internet services to make such factories operational in rural areas. Furthermore, the need for alternatives to fossil fuel for electrical generation is now even more apparent as pollution and greenhouse gases have decreased with the decrease in vehicular travel and aircraft flying. It is now visible that it is possible to have cleaner air and many can work from home, decreasing commutes in the future, after COVID-19. This is a dichotomous point in time and we can build from the positive aspects as we mediate the negative. But these “Green Projects” need an electrical grid.
Medical Infrastructure and Reserve
The urgent need to be able to allow commercial enterprises and schools to reopen is adequate testing and personal protective equipment. Some food and household items are in short supply and these needs to be addressed. Some agricultural products are in excess and finding a use, storage facilities and markets for these products needs to be more flexible as we move in and out of “physical distancing” limitations. Most importantly, we need to train a large corps of public health technicians to test, track and isolate those who are transmitting the virus.
This current pandemic is the worst since the 1918 Influenza pandemic, but as the world’s population grows and becomes more interconnected, another highly virulent and contagious respiratory virus could jump from an animal to humans and devastate humanity within the next ten years.
Can we be prepared before it reaches our country? (It could even start here in America).
Government funding to support private enterprise to build more hospitals, factories for PPE, pharmaceuticals, and all the necessary equipment to keep hospitals and clinics operating is needed right now. We need to again produce the basic chemicals that are needed for production of medication and laboratory reagents closer to the factories that produce the end products and not just on the other side of the world. Not that we cannot utilize products from other continents in the future, but we need the redundancy of local production in case of an emergency, whether it is another pandemic or a natural disaster. Also needed is funding to support both large and small businesses so that those businesses and their employees are there for us when the restrictions on our interactions end.
When an acute shortage of an essential supply occurs, the market will naturally drive the price to exorbitant levels. Health care and essential medicines are not fungible, like cars or large screen video displays. Price controls are needed, just as we do with essential utilities. The Board of Utilities assures that the utility companies make an adequate profit to remain in business and do research and development and expand to meet demand, but also assure that the customer of this monopoly is not exploited. This was done during WWII, because we were at war. Congress should actually declare a war against COVID-19!
As former President George W. Bush often pointed out, the country (and really the world), needs to always be prepared for a devastating respiratory pandemic. We need to recruit and train a large number of individuals to work in public health and be available to be called up, just as the National Guard or military reservists are called up in a natural disaster. We need to fund continual research in vaccine development, immunology and antiviral agents. We need to maintain a huge supply of ventilators, personal protective equipment and other essential hospital supplies such as oxygen and pharmaceuticals. If these items are warehoused, then they must be maintained and tested and reagents and other chemicals must be rotated out. Logistics must be developed and practiced prior to the next need. The National Health Service Corps needs a huge “reserve” just like the military. Young people need to have the opportunity to enlist in the NHSC just as they do in the military and get the same pay and benefits for their service.
Young people, many of whom have been laid off, or are facing financial insecurity, can be recruited to this effort to combat this virus, just as young people were recruited in 1942. This can be the Next Greatest Generation. The National Health Service Corps must be prepared to ramp up in emergencies, just as the armed services have reserve and National Guard units.
Massive Research Programs
The efforts during WWII to build the atomic bomb, known as the Manhattan Project needs to be duplicated to study and develop treatments and preventive measures against COVID-19. It needs to be much larger than the Manhattan Project and needs to involve research labs collaborating all over the world. The G20 such fund this project, and of course we are economically the largest member of the G20 and the only one with Treasury Department that can provide such large scale funding in the next few years. (Already the US Treasury is loaning money to Norway, Australia, Japan and Mexico to offset their financial strains and keep our trading partners viable during the COVID-19 pandemic).
Loans and grants to directly support businesses and the economy
Restrictions on physical distancing have forced many businesses to close down and lack of customers has forced others to furlough many of their employees. These former workers can no longer purchase much of what they did in 2019, often they cannot pay essential bills and purchase food. Many have lost health insurance in face of a pandemic. Some businesses need support to remain in business even when restrictions are loosened. Other industries need new logistics as consumer needs will be different for not just a few weeks, but many months or even years for some industries. We cannot continue to have food ploughed back into the fields while people are starving. The fragility of the American healthcare finance system is now grossly apparent.
A large expansion of industry is needed, just as it was in 1942. After WWII there were many grants for education, low interest housing loans and business startup loans. Construction and manufacturing took off. We need more housing desperately and some expanded manufacturing is also needed, but there is a huge need for new software and service products. The internet capacity needs to be expanded for business and for educational purposes, as teachers will need to be ready to switch to online for a week or two at a moment’s notice. Things are not going to go back to how they were in 2019.
The economy that developed in the fifties and into the sixties was not just focused on the consumer and the stockholder, but on the worker. When capitalism first developed after the middle ages, it brought most people out of poverty and created a middle class. The federal financial stimulation after WWII created good paying middle class jobs that allowed many families to move into the middle class. The federal financial stimulus package of 2009 was used to buy back stocks, increasing the value for the large stock holder, but the cost of healthcare and housing were skyrocketing and the average worker in 2019 was actually worse off than in 1999; basic needs were no longer being met by the income of nearly sixty percent of wage earners. The bank bailout increased the income disparity in the US and most of Western Europe. The actual living standard for Americans and most Europeans has gone down every year since 2008.
This distrust of the government because it seems to help the rich and ignore the poor has encouraged extremism on both the left and the right. This has discouraged collaboration and compromise (the keystone of a functioning democracy) has become a pejorative.
I am advocating a huge government injection of capital into the economy that is tumbling into an abyss, but unlike 2009, or even parts of the initial two CARES bills (Coronavirus Aid, Relief, Economic Security), the focus cannot be on bailing out large corporations that needed to be realigned in the first place, it must be focused on the needs of workers, families and health of the nation and the world.
That includes keeping state and local governments and the postal system solvent.
Some say that no stimulus can save an economy when it is on ice, but if we had left everything unrestricted, there would be no one to thaw out the economy in 2021.
What about the National Debt?
When the economy is growing and federal revenues are good (taxes, fees and tariffs), then it makes sense to try and pay down the national debt and decrease the interest cost to the federal government. However, when interest rates are extremely low, it often makes sense to invest in infrastructure, educational projects and healthcare both delivery (actually most healthcare in the US is funded by the government) and scientific research. In times of economic downturns and unemployment it will stimulate the economy and eventually restore federal revenues.
As noted before, in times of serious war, the federal government has underwritten most of the cost of combating the enemy. This enemy maybe invisible except under an electron microscope, but it is still a serious enemy causing massive destruction. We are at war!
What about the risk of inflation?
In times past, when the federal government printed large amounts of money and injected these funds into the economy, it has stimulated rapid increases in both wages and the price of consumer goods. This was quite extreme from 1978 through 1982. Currently the rate of inflation is very low, based on 2019 and most of the last two decades. The financial collapse of 2008 required a huge influx of capital by the federal government and yet we had deflation in 2009. With the economy collapsing, we are at risk of serious deflation, so inflation should not be our worry until the risk of COVID-19 to the economy is totally gone and we are fully prepared for the next infectious or natural disaster.
The need for a new financial system and economy
The bailout of large banks after the 2008 financial collapse allowed the economy to continue to function and kept banks “too big to fail” open as well as General Motors. But many small investors and retirees suffered severely and many small and even medium companies failed. Since that time we have had a massively widening income gap and it has left young people, especially the “Millennial Generation” and those following with a very bleak future. Now with the economic collapse by COVID-19, they and the vulnerable members of our society or suffering the most.
The 21st Century’s “Greatest Generation”
We need to develop a cadre of individuals who are dual trained, similar to the National Guard and the military reserves. People who may have accounting or programing or sales, or any number of other jobs most of the time, but can be respiratory therapists, laboratory technicians, nurses, public health technicians or psychiatric aides one weekend a month and two weeks during the year. This service should forgive their student loans.
The need for a strong educational system
School closures have taught us how much teachers contribute to the development of our children and what a difficult job that is. We now should recognize the need to develop our schools. While schools are closed, we should be fixing the outdated structures and systems in our schools and updating our schools for better use of the internet, so when the next catastrophe closes schools, teachers can still connect directly with their students in small groups online for at least 30 min to an hour each day, more in high school. We also need to look at the funding needed to attract the brightest and best college students to enter the teaching profession.
Initially start with production of adequate PPE and testing supplies for this specific virus. Then work closely with public health experts to see what restrictions could be loosened safely in May (or June, if Congress is too slow to act). Carefully outline a plan that starts development of the next projects and simultaneously start a recruiting program for a national, or state based corps of workers to fight the fight against this virus and then move back to their regular vocations as the restrictions allow, but continue to be ready to return to the fight when the need arises, and it will.
A solution that will end COVID-19
It is possible to eliminate the virus causing COVID-19 within a year, but it would take a huge investment and greater cooperation than the world has ever seen. However, if the democracies in the developed countries could work together and make the investment to stop this deadly terror, it could be done, just as the world eliminated small pox, even from war torn countries during the 1970’s.
Initially huge amounts of testing capacity and public health contact tracing would need to be created. This will take a few months. Also adequate PPE needs to be manufactured and distributed throughout the world, as the virus is all over the world except New Zealand, possibly Iceland and a few very small islands. China and the Western Democracies would have to agree to cooperate on this effort and not try to out-compete each other for favor in the developing world. Food supplies and water, or sanitizer would need to be distributed all over the world. This would require a multi-national peace corps. Once the supplies are all in place, including in Yemen, Syria, Venezuela and other war torn areas and especially in refugee camps and other places of crowded living at a poverty level; 30 days would be designated when the entire world would “shelter in place.” With adequate testing, some small communities with no positive cases could interact with each other, but generally, everyone would remain at home, or go to essential work only with full PPE. Rigorous testing would continue and all cases strictly isolated, therefore isolation facilities would need to be established in advance and efforts would have to be made to either increase hospital capacities, or reduce the hospital census of elective cases. Care homes for the elderly and disabled would need to have their workers camp or be lodged nearby for the 30 days.
At the end of these 30 days, all cases in the world would be known and isolated. Once these individuals had recovered, SARS-CoV-2 would be extinct and COVID-19 would be a memory.
The benefit to the world of such a massive cooperative undertaking would also reduce a lot of distrust between nations and peoples and encourage cooperation in the future on other issues such as alleviating poverty and stemming the tide of global warming. The challenge would be preventing corruption when so much money is involved.
Congress must act immediately
The effort needed now and for the next couple of years to fight this war against the virus that causes COVID-19 will need to be as great as the effort put forth from 1942-1944. In today’s dollars, that would be $6 Trillion. Congress has already committed $2.2 Trillion, but it could be easily necessary to spend another $6-8 Trillion to both restart and stabilize the economy and prepare for the next major disaster, whether it is a pandemic, or a huge earthquake on the Cascadia Subduction Zone.
It will take a huge effort by all Americans, and in reality, by everyone living on this planet. Cooperation and collaboration is essential. Political demagoguery must end. The elderly and infirm are most hit hardest by COVID-19 directly, but young people are being hit hard by the economic ramifications necessary to keep the virus from spreading rampantly. Mostly stuck at home, or working without adequate PPE, the sacrifices these young people are making are huge.
We Must Act Boldly
Adequate funding for large corporations to survive and/or convert their production is important, but more importantly we need to keep small and medium business functioning and make it possible to keep their employees paid and covered by health insurance (although now we need to reconsider how to provide universal coverage). We need to have a corps of individuals trained and ready for the next pandemic, just as we do for more physical natural disasters. We need to fund and develop a reserve corps for the National Health Service Corps, just like we do for the Army, Navy and Air Force. It will be necessary to significantly increase the national debt, but once the economy is back and operating fully, as well as protected from future infectious disasters, we can determine how best to gradually shrink the national debt.
Failure to act now and invest in the future of the world’s economy (we’re all in this together), will result in a second surge of COVID-19 and a long lasting depression.
 Treasury Direct Archives.
 Budget cuts caused a huge drop in GDP in 1946 and a long recession, but 1950-1959 saw huge economic growth, excluding 1954 and 1958 (brief recessions), which included 6 years of over 4% growth and one year of 8.7%. Bureau of Economic Analysis. “Gross Domestic Product”
 Gita Gopinath, economist at IMF, quoted in The Wall Street Journal by Josh Zumbrun 14 Apr 2020.
The predicted world economic contraction for 2020 is 3%, compared to 0.1% in 2009.
 Csiszar J, GOBanking, 27 Mar 2019.
 BRAC (which coordinates emergency aid) published In OHCA Services, 9 Apr 2020.
 Davis KC, Smithsonian Magazine 21 Sep 2018; More Deadly Than War
 Tom Brokaw, momentous change, work ethic, frugality, sacrifice and honor.
 Abiy Ahmed, 2019 Nobel Peace laureate, 25 march 2020.
 Washington Post, which states the first recognized case was 21 Jan, a Seattle man who had just traveled from Wuhan. There is now evidence that the virus arrived even earlier and began to spread in Santa Clara County, California.
 There is good evidence developing that the virus may have been in Santa Clara County, California earlier, including at least one death (Bendavid E, Mulaney B, et al, Covid-19 antibody seroprevalence in Santa Clara County, Calif; BMJ, doi: https://doi.org/10.1101/2020.04.14.20062463, accessed 27 Apr 2020-although there are several serious statistical problems with this study, it does verify at least limited transmission earlier) and likely earlier existence in Wuhan by several months (Andersen K, Rambaut A, Lipkin WI, Holmes EC, Garry RF, The Proximal Origin of SARS-CoV-2, Nature Medicine, 17 Mar 2020).
 Seattle Times, updated online Mar 21, 2020.
 University of Washington School of Medicine Newsroom: newsroom.us.edu, although a Mar 1 update indicated that the virus had been in the Seattle area for at least a couple of weeks before the initial case was reported 24 Feb 2020.
 MERS Middle East Respiratory Syndrome, a novel coronavirus that jumped to humans in 2012 in Saudia Arabia and threatened to spread all over the world. There were 186 cases identified in May 2015 in the Republic of Korea, so the Regional Emergency Operations Center was activated and the spread was quickly stopped. S. Korea has kept this team and its support staff in place and increased its size and funding, so they were able to quickly identify and isolate any cases of SARS-CoV-2 before COVID-19 could spread through the country.
 Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19), 16-24 Feb 2020.
 Andrea Remuzzi, Lancet 13 Mar 2020.
 Brown E, Tran AB, Reinhard B, Ulmnau M, US deaths soared in early weeks of pandemic, far exceeding number attributed to covid-19, Washington Post, 27 Apr 2020.
 Lee TH, Creating the New Normal: The Clinician Response to Covid-19, NEJM, 17 Mar 2020.
 Christian Drosten, Chief virology, Charity Hospital, Berlin, NDR 7 Apr 2020 (Considered the foremost authority on SARS-CoV-2 in the world).
 Robert Koch Institut (a nonprofit that is essentially the CDC for Germany) https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Risikobewertung.html
17 Mar 2020 and updated 23 Apr 2020.
 Aubrey A, NPR, 22 Apr 2020.
 Work from the University of Washington Institute for Health Metrics and Evaluation as reported by NPR on 24 Apr 2020: https://www.npr.org/sections/health-shots/2020/04/25/844088634/when-is-it-safe-to-ease-social-distancing-heres-what-one-model-says-for-each-sta accessed 25 Apr 2020.
 Recommendations of the Robert Koch Institut, Berlin Epidemiologisches Bulletin, Ausgabe 17, 23 apr 2020
 Christian Drosten, NDR, 20 Apr 2020.
 https://fortune.com/2020/04/06/uk-boris-johnson-coronavirus-icu-herd-immunity/ accessed 24 Apr 2020.
 https://www.sciencemag.org/news/2020/04/south-africa-flattens-its-coronavirus-curve-and-considers-how-ease-restrictions accessed 24 Apr 2020 and “Morning Edition,” NPR 24 Apr 2020.
 https://www.health.harvard.edu/diseases-and-conditions/treatments-for-covid-19 accessed 24 Apr 2020.
 Prompetchara E, Ketloy C, Palaga T; Immune Responses in COVID-19 and potential vaccines: Asian Pacific Journal of Allergy and Immunology; 2020;38:1-9.
 https://www.cdc.gov/coronavirus/general-information.html accessed 24 Apr 2020.
 Kristof N, This Pandemic is Bring Another with It; NY Times, 22 Apr 2020.
 Ibid Christian Drosten
President George W. Bush, 2005, his admonitions to his cabinet after reading about the 1918 influenza pandemic.
 Exorbitant Privilege, Exorbitant Respnsibility; Planet Money, npr.org 21 Apr 2020.
 Weik M, Freidric M; Der groesste Crash aller Zeiten: Wirtschaft, Politik, Gesellschaft. 2020.
 Mitch McConnel 25 Mar 2020.
 https://www.usinflationcalculator.com/inflation/historical-inflation-rates/ accessed 25 Apr 2020.