Let’s End COVID-19

I seemed to be floating above my body and rotating around by the ceiling looking at my son and wife crouched around my bed with heads bowed. Then I was back in the bed and the sounds of machines and lights of the ICU were more apparent. The sedating drugs were wearing off. Aggg! I was on a ventilator and was becoming awake. A giant lift had just lowered me from near the ceiling into a bed, but I could not remember anything since being wheeled through the doors under a bright light “EMERGENCY.”

 

I was in the hospital where I was a professor. I had put a lot of patients on ventilators and knew that sometimes they had to be nearly awake before they could come off the ventilator. This was miserable; the machine was forcing air into my lungs at what seemed like the wrong time. My wrists were restrained. Of course, a mildly sedated patient would try to remove the tube forcing air into their lungs. As the hours went by, the sedation wore off and I really did want to yank the tube out.

 

My son came and held my hand. I tried to write into his palm. He got the nurse to loosen my right wrist. He put a pen in my hand and held paper so I could write. “No Dad, you’ve got to breath deeper on your own.”

 

“I’ll set the vent to assist/control,” the nurse said, “it will trigger when you want a breath.” I knew it would also trigger, if I waited too long to breath and it would force a full breath in no matter what.

 

Hours passed and nutrition poured into my veins. Eventually I could breathe adequately on my own. I could have just as easily lapsed back into a coma and they would have stopped the ventilator once I had been declared “brain dead,” as it stated in my living will.

 

My son and wife were back at my side. “It’s time to retire.”

 

Five days previous I had spent twelve hours in surgery having a cancer removed from behind my pancreas and other complications treated. I had a low grade lymphoma already. I was an endocrinologist teaching in a busy medicine clinic. I now needed to avoid any infection.  Time now to finish the book I had worked on for years.

 

My wife and I would now have to isolate every winter during the influenza season. We set up our home to ‘shelter in place.’ That was two years ago. I read the medical literature related to my book and my unusual cancer that kept recurring. Then in January 2020 I read about a strange new pneumonia in Wuhan, China.  My son had been there, my sister had just moved back from Nanjing and a friend was still in Shanghai.

 

By February I could foresee the path this novel coronavirus could take.  I read everything I could from German virologists and epidemiologists before they were available in English. I knew the economic impact would be huge, even if we could keep the virus out of the USA. It spread must faster than expected, and unlike Germany, we were not prepared.

 

In March efforts were taken to avert a catastrophe by the Federal Government, the Treasury, Federal Reserve Bank and Congress. I looked carefully at what other governments were doing. I looked at historical documents from the 1918 Influenza pandemic, the 1929 crash, the financial effects of WWII and historical economic data from the last seventy years. Not just public health problems loomed, but a real financial crisis was developing and would encompass the whole world.

 

I came up with a plan and developed a detailed paper on what could shorten the course of the disease spread and significantly curtail the economic disaster.  Since then, a lot more scientific data and research has come out, which I have carefully studied. “When we have a vaccine or cure, then we can go back to normal.”

 

We are not going to go back to 2019. It will take years to develop and distribute a vaccine and many will refuse to take it. An easy cure or preventative is not in the immediate future.

 

We can learn to adapt to an altered life with COVID-19 ever present, ever hindering the economy.

 

OR WE CAN ERADICATE SARS-CoV-2.

 

There are actually four plans, three of which have good data and have been proposed, and my ultimate proposal, which has an indisputable excellent final result from both a medical and economic perspective, but will be extremely difficult to execute. It is technically not impossible, and therefore deserves discussion.

 

Plan 0 (zero) – this is to do nothing, let the virus run its course and infect a majority of the population, but put no restrictions on any economic activity, schools or social interaction.  It has been proposed and even to some extent executed either intentionally (Brazil), or through local disorganization (El Salvador). Most government leaders have not felt this was feasible as the initial proposed death rates would be unacceptable and the medical system would be overwhelmed. However, in retrospect, some are proposing that at least for some parts of the world, including some parts of the US, this should have been the plan. So I will present the data, as we understand it in June 2020.

 

Plan A – this is the status quo.  This is what we have done in all its convoluted, disorganized manner. It is uncoordinated in its execution, even within states and definitely between states. There is little international collaboration, other than some vaccine research. There has been a huge liquidity input from the Federal Reserve and help from the Treasury, which has kept the stock market from falling into a depression (yet).  What will happen when the earnings reports come out for the 2nd quarter, or the 3rd? Congress has rescued major businesses and given token support to small and medium businesses. Some support has been extended to those hurt economically, but bankruptcies are going to soar, even if the economy is completely reopened  soon. Millions are out of work (2019 was 3.5%, as low as the Federal Reserve believes is possible—the Goldilocks Economy—low unemployment and low inflation. Now it is over 14% and rising, the highest since 1938. We may even break 24.9%, the highest ever recorded—1933, just before the start of “The New Deal”).[1] The curve has been flattened, with a significantly lower infection rate than Plan 0, but the economy is abominable.

 

Plan A is having abysmal results and some hospitals are being overwhelmed (NYC, Trenton, Detroit and Gallup). The economic results are atrocious. The reactions of many US citizens are alarming.

 

The pace and severity of the infection varies greatly from state to state and from county to county within states. Some areas have been severely hit and everyone knows someone who has died or is now severely disabled. In these communities few are willing to venture out, even as restrictions have been lightened. In other place most residents have no personal experience with COVID-19 and are bucking against what seem like unnecessary restrictions on their normal activities and especially their livelihood. If we had followed Plan 0, more places would have had first-hand experience with this devastating virus and places would have closed permanently, due to lack of customers. Under Plan A many people are chaffing at the bit to reopen and questioning the necessity of any “lockdown.”

 

What if places reopen and then are hit by a “second wave” and have to shutdown again?

 

Plan B—a Battle Plan. We are really at war, only this time the enemy is an insidious, invisible virus that is destroying lives and the economy and racking devastation across the globe.  We need to be on a War Footing.  From 1942-1944 we invested heavily in the war effort to manufacture what was needed and enlist the individuals needed for the fight. The national debt ballooned to the highest ever, but employment dropped to the lowest and from 1949-1961 the economy had the longest running growth period and the national debt was nearly eliminated. Why shouldn't we make the same kind of investment in a war against COVID-19? Why don’t we invest in a project larger than the Manhattan Project to find a cure, while at the same time investing in testing, contact tracing and personal protective equipment so that those on the front lines of this battle are safe? We can put most of those who have been furloughed back to work. Initially they will not be at their former job, but working in manufacturing, health care, public health and data analysis. This war has to be fought on a worldwide basis, but once it is won, people can safely go back to how things were in 2019.  However, Plan B is going to actually take years and more international cooperation than is currently being demonstrated by world leaders. Much of Plan B has passed the House and now awaits the Senate.

 

Plan C—the comprehensive, conclusive, fairly rapid and definitive plan that would end COVID-19 and set in place a system that can quickly be implemented the next time a highly contagious deadly virus appears. Plan C will not be easy and will require a huge financial investment and the cooperation of the whole world.  Plan C will be very difficult, but it is not impossible, so let’s discuss actual eradication of SARS-CoV-2, the virus that causes COVID-19. It doesn’t matter where it started or how, who messed up or didn’t, was the shutdown needed or not, let’s work together and unite to fully eradicate this virus from the planet. This eliminates the uncertainty of when this all will end, which is not clear in the other plans.

 

Plan 0

 

The economic consequences of what we are doing are huge and well documented. Many have stated we have been over-zealous and restricted our economy unnecessarily. So let’s look at Plan 0 and what the economic consequences would be if no “social distancing,” had been recommended, all schools and businesses and day care facilities had been left open. If things in April had been the same as the US was in January, where would we be in June?

 

A careful economic analysis done on 24 March 2020 with data from Europe, where the virus was spreading rapidly with devastating results, showed what would happen in the US if no economic or social restrictions were instituted.[2] Scherbina’s paper has been updated (1 May 2020) to show a suppression phase, which was instituted to some extent in some places, followed by a mitigation phase, which we are entering in many areas. She lumps the whole US into a single data collection, so what happened in NYC is much worse and what is currently happening in Eastern Oregon or most of Wyoming is much better.  Her original paper, early in March, showed $13 Trillion as the cost of letting the virus run its course with no restrictions. This is based on 60% of the population getting infected and a death rate of 2% and a cost of medical utilization based on 2019 influenza epidemic. (There are four versions of this article and I will utilize quotations from the first and last).

 

The medical costs are adjusted for the estimated increased cost of the virus based on European data from earlier in March. This is actually a gross underestimate, as medical costs in the US are much higher. Also there is a larger indirect cost in the US healthcare system, as reimbursement for COVID-19 is significantly less than the actual cost of caring for these patients in the hospital. At the same time that the COVID-19 pandemic was rapidly spreading in the US, most hospitals were not performing any elective surgeries, which is how hospitals actually generate income to cover the cost of caring for patients with pneumonia or congestive heart failure.  This is not the system in Europe. Also, initial evaluation by Scherbina divided patients into four categories: asymptomatic or very mild cases, those that need outpatient care, those that need to be hospitalized and then survive, and fourth, those who are hospitalized but die, using an average length of stay before death of 21 days and only 14 for those who don’t die.  In reality, the death rate in the US was much lower than Italy or Spain and more like Germany, but with the average person who survives spending nearly a month in the hospital.

 

Also not included in the costs is the revelation now developing that many individuals never get admitted to the hospital, but are too ill even two months after first getting sick to go back to work, and that many who survive hospitalization end up for weeks in rehap centers and are still needing rehab as outpatients.[3]  Many of these patients are in their 40’s and 50’s. These are in their prime of their work and income. Many were previously healthy and had management positions. Therefore, the economic costs both of direct medical care and indirect loss of productivity from sick workers is much higher than Scherbina forecast, even for Plan A, but especially for Plan 0.

 

The European data showed that uninhibited, R0=3.8, and she used 2.4. R0 is dependent on the closeness of contacts, so in NYC on a subway or elevator R0 would be nearly 5 and in rural communities it could be less than 1, so 2.4 is a fair assumption for the country as a whole, but distorts the rate of spread, as the virus would spread very rapidly in the Northeast, but take longer to reach most of the West and would spread more slowly, especially in some rural areas.  But when it does spread, it spreads exponentially even in some rural communities.

 

R0 is the rate at which an infectious agents spread. R0 of 1, means that each infected person only infects one other person. The number of infected individuals stays the same. R0 of less than 1.0 means the virus will eventually nearly disappear, as usually happens in the spring to seasonal influenza, even though it may have had an R0 of 3.0 in December. R0 of 3.0 means that on average, each infected person infects 3 other people, who then infect 9, who then infect 27, who then infect 81 and so on. It was initially worse than that in Queens, NYC.

 

Scherbina assumes a mitigation strategy that is nationwide, when a more localized strategy was used. The direct cost of caring for the sick assumed that those hospitalized would average 14 days. The US has a very convoluted healthcare finance system, but, about half the medical expenses are paid by taxpayers. Her estimate was that $1.2 Trillion would be needed to cover the cost of direct medical care. We have since discovered that people often spend much longer in the ICU and may need months of rehab before returning to home, let alone work. We also have discovered that COVID-19 is not dichotomous. Her initial estimation was based on the ill either dying within 14 days or returning to work within 14 days. This is not the case. Many patients spend weeks in the hospital before they die or will spend months in recovery before they can return to work, if ever. The medical costs of Plan 0 would be closer to $5 Trillion and the economic cost of lost productivity and the fear of consumers would be greater than 50% of GDP (an additional $10 Trillion).

 

In early March we did not know that many, including younger patients, would develop permanent heart failure, kidney failure requiring months of dialysis, liver failure that saps ones energy and strength, neurologic disorders that make walking impossible and worst of all encephalopathy or stroke. We now know that the virus has caused serious heart disease in over 300 children. Encephalopathy causing a future engineer to not even be able to work stocking grocery shelves and will need to be in a sheltered workshop, possibly for the rest of his life. The number of healthcare workers getting extremely ill and even dying was unanticipated. (We still do not know how much children can spread the virus, but we now know that they too can get seriously ill).

 

Some have advocated that Plan 0 would allow “herd immunity” to develop over the course of several months and that would slow the spread of the virus to an R0 of less than 0.2.  Spain has recently tested 70,000 citizens at large for antibodies to SARS-CoV-2. Spain had the worst outbreak of COVID-19 in the world, which included more than 27,000 confirmed deaths. With a population of 47 million, that is 37 deaths per million residents. The US has the highest total deaths of any country, but only 10 deaths per million. In hard hit Madrid, 14% have antibodies, but as a country only 5%.[4] To achieve herd immunity of 70%, the death rate would be 518 per million (1.9 million fatalities in the US) and the disability rate at least twice that. Sweden tried this, but now regrets that decision.[5]

 

This brings the cost to the US of not doing any restrictions to over $9 Trillion directly and much more indirect costs (lost wages from missed work) of possibly another $15 Trillion. This is actually a low estimate, as initial calculations assumed that most hospitalized individuals would be on Medicare and many would die soon after admission, but a very large number are much younger and even the elderly live for weeks in the hospital, with most actually being discharged, but not back to their home.

 

The economic cost of doing nothing would be an economic disaster. It would eliminate large gatherings and schools would be closed as so many teachers would have died or become incapacitated. It would be 3-4 times the proposed $6 Trillion that Congress is proposing to lift up a collapsing economy.

 

Plan 0 would likely result in 55% of the population being infected over the course of a year, 1.3 million fatalities and medical costs of $9.08 trillion, or 42% of GDP.

 

Plan A

 

The current restrictions on interactions varies greatly from state to state, as each governor consults with different experts to formulate a plan. Severe restrictions are in place where the population is dense and early cases have spread rapidly. The plan is to suppress the spread of the virus and “Flatten the Curve,” to keep the healthcare system from being overwhelmed and hopefully limit the spread and the consequences (both death and disability) of COVID-19 until a vaccine or treatment is widely available. Next is mitigation, which is widespread testing, tracking contacts and isolating those infected individuals for 14 days.

 

There has been much protest from the highest level about the “suppression” (lockdown) and its effect on the economy and mental health as well as scholastic achievement. So many areas are moving to “mitigation” but without real “mitigation” (limited testing, almost no contact tracing and no facilities for isolation).

 

The risk of a second wave of infections in many areas is very real. A suppression phase until widespread vaccination would last years and not only demolish the economy but would become unendurable. At what point can the cost of suppression exceed the cost of new cases? If we cannot even tolerate a single life being lost prematurely, then we must suppress until a vaccine. We cannot just ask the elderly and immune compromised to isolate, as young, healthy people die too, or worse yet, are severely disabled for life.

 

Health care economists actually put a specific value on a life. It is arbitrary and does not apply evenly, as some people may add a huge amount to the economy and others little, but using ethical guidance, everyone is counted equal: $50,000 per quality year. Defining a year of quality life is also arbitrary but is defined as having the capacity to interact with others (advanced dementia, persistent vegetative state, or stuck on a ventilator and unable to communicate). By this measure, a forty year old is worth twice what a sixty year old is worth, but it gives us a number to use that is not limited to earning capacity, and remember, retirees may still contribute a lot and can make significant purchases in the economy.

 

To see how Plan A is working over the next three months, we must make assumptions. Full lockdown as instituted in the UK, which has isolated itself from the rest of Europe brought the R0 down to 0.62.[6] So the number of cases of COVID-19 were going down and the virus would disappear, if the lockdown were continued. If we then move to mitigation with widespread testing of at least 5% of the population per week (almost 20 million), strict contact tracing and isolation of all positive cases; the R0 would stay low and the virus would eventually disappear. However, we are not doing that, and R0 will be much higher in most of the country, although still low in isolated rural communities.

 

If we could keep R0 below 0.7, then the cost of the pandemic for the next 18 months (minimum time anticipated for a widespread, safe vaccination program) would be about $9-10 billion in direct medical costs and about $20 billion in indirect costs. Much less than the trillions anticipated in Plan 0. Plan 0 would probably have 3-4 million deaths and another 10 million or more permanently disabled. Plan A with excellent mitigation would probably have less than a million total fatalities. Assuming each had on average only 6 quality years left, that is $600 billion, but more likely a couple of Trillion added to the $30 billion above.

 

Unfortunately, we are not testing at the necessary level, we have not hired and trained adequate contact tracers and we have few good places to truly isolate those infected individuals while they could be spreading the virus.

 

So, the real costs to the US in the next 18-24 months will be significantly higher. Easily a Trillion in direct medical costs, 3-4 trillion in lost productivity. Another 3-10 trillion decrease in GDP, as many individuals have stated that they will not go to theaters, sporting events, ride airplanes, let alone cruise lines, or even go to restaurants. Plan A will put a damper on the economy for years. A recent Marists poll states that 75% of Americans fear a second wave and are going to continue to limit their shopping and other activities that expose them to others.[7]

 

In three months, we have surpassed 100,000 deaths. What will another year bring? If the fatality rate exceeds 3000 per day, then we will just pass a million in less than a year. Most epidemiologists expect that rate to double or even quadruple in coming months (the second wave in the fall), although currently we are below 1000 and that may hold for the summer.

 

Since there is no national coordination of lifting the restrictions to suppress the spread of the virus, things will vary from state to state, but even this will get messy as there are no restrictions on travel and interstate commerce is considered essential.

 

Scherbina looks at the likely outcomes of different lengths of suppression before moving to a phased lifting of restrictions.  She also looks at the economic consequences of opening up and then needing to return to the suppression phase (essentially shelter at home).  She assumes an R0 = 0.5 during suppression, so restrictions would be tight and actually adhered to.  During mitigation, she assumes that most people will wear a mask in public and remain 6’ from others and groups would be limited to less than 25. This would mean that R0 = 1.1 during the mitigation phase.  (Of course this is not what most people are doing). COVID-19 would continue, but the spread would be small and the number of new cases would remain constant over time. The healthcare system would function normally, but businesses would need to make significant accommodations and some would not be able to open until a cure or vaccine is available. If R0 could be held below 0.5 through June 20, all known cases of COVID-19 would be isolated and spreading could be stopped. In another month, there would not be any new cases domestically; only cases coming from outside the US would infect US residents. Quarantine of new arrivals would prevent even that. But we are not doing it, testing is still limited and the number of new cases is still growing. Not as bad as it was in April, but still over 20,000 confirmed new cases per day and probably at least that many undocumented cases.[8]

 

Over the course of the rest of 2020, an R0 of 0.7 has a medical cost of $20.18 billion, an R0 of 0.5, is only $8.72 billion. We are not getting close to R0 of even 1.9 in most of the US, so the medical costs of trying to “save the economy” is going to be over $40 billion, mostly paid by taxpayers.

 

If we stay in the “suppression phase” there is an economic cost from decreased productivity and purchase of some goods, (but especially entertainment, restaurants and travel) of about $17 billion per week, or a Trillion for a full year. However, there are decreases in travel related deaths and injuries and crime in general. Less pollution means less medical costs for asthmatics and others with lung disease. Some workers have demonstrated increased productivity while working at home. So the actual cost maybe less, although the cost of mental health and personal bankruptcies could offset any benefit and the quality of home schooling for most children under the suppression phase is marginal.

 

“Optimally, the lockdown should end before its incremental benefit falls below its incremental cost to the economy.”[9]

 

Therefore, if the “lockdown” were to have continued until the middle of June, the savings in medical costs and lost productivity from the virus spreading more rapidly would be $3.54 trillion more than the actual cost to the economy, if an R0 of 0.5 is attained, on average nationwide. If the lockdown were extended until July 1, then the savings would be $3.83 trillion, or almost 18% of GDP. This would significantly suppress the spread of COVID-19, and the total number of Americans infected would be less than 3 million by the end of the year, assuming a minimal second wave in the fall.  Extending the lockdown beyond July further suppresses the virus and further reduces the actual medical costs, as less people need medical care. It also expands the economic cost, so beyond July, the economic cost is greater than the medical costs saved.

 

However, if partial suppression is continued after the lockdown is lifted, the number of deaths and those suffering long-term disability drops and the Quality of Life calculation starts making the cost of fully opening the economy much higher than the increase in GDP, assuming that total lifting of restrictions would return the economy to where it was in 2019, which it would not.  Therefore, there can be significant economic benefit to restricting gatherings to small groups, screening all before the gathering, eliminating singing at church or other group activities, mandating that everyone wear a mask and “social distancing” as much as possible. This QUALY calculation would add another $0.9 trillion to the $3.83 trillion noted above.

 

Even then, though, the elderly and vulnerable and their care givers will not be out shopping, attending theaters or buying tickets to concerts or sporting events for a year or two, if ever, so this must be subtracted from any potential gain in economic activity from lifting restrictions. Lockdown does not benefit after July 1 in most parts of the country, but might be needed in certain “hotspots.” However, mitigation restrictions will be of benefit in reducing healthcare costs greater than economic loss from the restrictions until we are clear of a second wave—probably November.  Adding in QUALY analysis, the benefit of strong mitigation remains positive until early January, at which time the number of active cases would be small and the risk of spread could be limited by widespread testing, contact tracing and isolating those few cases until they were no longer contagious.

 

What happens if we loosen restrictions too quickly and there is a huge second wave and it becomes necessary to reimplement the “shutdown.” A second wave might only require localized restrictions, but more likely would impact major metropolitan areas and shut down travel, manufacturing and effect the economy of the entire US and impact the world economy. A second wave would start with a doubling of new cases every 3-4 days in a city or area. It could easily spread to adjacent states and other countries. If restrictions were not implemented quickly, it could quickly infect another 3.5 million people.[10]  The medical costs would be nearly $4 Trillion. The cost to the economy at $36 Billion per week could quickly diminish GDP by 4-5%, not to mention all of the workers who are trying to recover from the last lay-off being forced into bankruptcy and homelessness.

 

Children

Children rarely get very sick, although a few do. They can transmit the disease to adult household members, but the spread between children is less than most other respiratory viruses. Schools have been closed to decrease the spread and help flatten the curve. Most states are anticipating opening schools up as normal in the fall of 2020. A second wave in the fall would force schools to close again, many children would not be getting the education needs met and no child will be having an opportunity for vigorous play and the social interaction that is so much a part of growing up.

Aggressive reopening might help the economy to recover, but our children may suffer as a result, when most schools are closed again as second and third waves spread over the country this fall.

Herd immunity is not a viable option, but suppression until the virus can either be easily prevented, treated or isolated is doable, but will require more effort than we are currently expending. We should support the economy until the “dance is over.” (Hammer and Dance)[11]

 

Conclusion: We are not doing nearly enough to control the spread of the pandemic. Some governors will be forced to reinstitute restrictions which will cost the economy far more than if they had extended the restrictions another 2-3 weeks to allow the public health system to track and isolate active cases.

 

Plan B

 

We are not doing enough now, but that does not mean we cannot aggressively battle against the spread of COVID-19 to allow everyone to again safely participate in normal activities and simultaneously infuse capital into the economy so that there is an economy to return to.

 

Taking a more aggressive approach to attacking the spread of the virus will require a substantial effort and will not be inexpensive, but could get us quickly to R0 below 0.5 and most people will be comfortable with reopening schools in the fall, but Congress will need to act quickly. The economy will never really reopen until nearly everyone is assured that the risk of contagion is extremely low.

 

New Zealand, Iceland and Taiwan have very successfully stopped the spread of the virus in their countries. For Taiwan this was especially noteworthy as they have over 23 million residents and a lot of trade. From the onset, Taiwan had obtained a large quantity of testing supplies. Taiwan still had in place a rapid response public health system from the original SARS epidemic in 2003. Cases were quickly identified, contacts traced and tested, all positive cases isolated until no longer contagious. Increased alertness by everyone and cooperation was complied with, but no restrictions on the economy.  It should noted, that mask wearing is the custom by nearly everyone living in Taiwan.

 

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.[12] 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.

 

National debt has been growing over the last two years, but Congress has not seemed concerned until requests to reboot the economy have been proposed. With interest rates low and with the dollar being the international reserve currency, increasing the national debt now is even less consequential than it was in 1942 and the enemy we are facing is much more dangerous. States and local governments, hospitals and schools, small businesses and individuals are facing economic catastrophe.  Funds to stabilize these institutions and prevent another Great Depression are essential and will not burden the next generation any more than the “Greatest Generation” was burdened during the 1950’s by the huge national debt that shrank slowly as federal dollars were put into creating housing and building the infrastructure of roads and an electrical grid.

 

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.[13]  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.

 

Additionally, funds used to create testing, adequate “personal protective equipment” and a robust public health system would make it possible to quickly reduce R0 to below 0.5, at which time testing, tracing and isolation would further stop the spread and threat to the economy.

 

During WWII much of the factory output in the US was directed toward the war effort.  Government price controls were required because of supply shortages. Many companies had essentially a monopoly on certain products and so were regulated, just as we do with utility companies. This assures an adequate profit, but also a reasonable price on limited items.  The same thing is necessary for items currently in short supply, but especially for any vaccine that is developed and realistically all medications, as US pharmaceutical companies have a monopoly on most products.

 

As a contingency in case of conflict, we maintain a large military reserve for all branches.  These reservists serve one weekend a month and another 2 weeks per year, often doing a job in the civilian world that is not the same as their military duty.  The National Health Service Corps needs the same kind of reserve system. The NHSC also needs a large corps of enlisted do basic services in hospitals during a disaster and most importantly to support the public health system during a pandemic.

 

School closures have also taught us how valuable our teachers are. We need to build a stronger education system for all children and young adults in any neighborhood. We need to develop a substantial yet flexible curriculum that can quickly migrate from in classroom to online with teachers provided with the pedagogical resources to make learning effective under either situations and also be able to assure that students have the emotional support that is necessary.

 

We cannot isolate ourselves from the rest of the world. Trade and travel are usually essential. So we need to work with all other countries, both friend and foe to combat this threat to humanity together. A vaccine or cure is very remote, but we must give support to researchers all over the world and if something successful is discovered, we must work to make sure that it is available all over the world.

 

Developing countries do not have the resources to combat COVID-19, so we and other more developed countries must unite to help those countries not only “flatten the curve,” but try to limit the spread to those countries by any means reasonable. Waring countries around the world must make a truce so that aid groups can be involved in stopping the spread into war-torn areas and refugee camps. Efforts to bring hygiene and fresh water to those parts of the world lacking these basics are the duty of all developed nations. (Including assuring that all Americans have fresh water, even the poor inner city residents and Native Americans in isolated villages).

 

Germany and France have proposed a massive influx of funds into the EU economy and Germany, with much less resources than the USA will be footing most of this bill. Angela Merkel realizes that the economy has been severely hampered by the necessary economic shutdown, especially in Eastern Europe. The need to keep people fed, healthcare operational and small businesses operational is essential for a recovery and these bonds are providing far more benefit than risk.  The US Congress should do the same and put another $3-5 Trillion into a recovery plan. Both Steven Mnuchin and Jerome Powell advocate this.

 

Aggressive testing, tracing and isolation will not eliminate the virus. A vaccine would only work if nearly everyone is vaccinated and there is already a huge resistance to a vaccine that has not yet even been developed.  A medical “cure” is very unlikely. However, slowing the spread to a crawl will make it possible for most people to return to the economy.  Unfortunately, the elderly, medically vulnerable and their care givers will need to continue to take extreme precautions indefinitely. A single asymptomatic carrier at a basketball game could quickly cause a huge resurgence of COVID-19 with death and disability to the vulnerable not at the game.

 

Current testing is limited and of course needs to be ramped up, but improved quality of testing needs to be done as well.  The actual standard is to repeat every positive test and any negative test of a symptomatic individual.  False negatives are common from technique failure.[14] Also of concern is a low positive predictive value of the test when processed by a lab that is under pressure to do a lot of tests at a high rate.[15]  This is not as bad as the low positive predictive value of the antibody test, but can be an explanation for the large number of “asymptomatic carriers” that don’t seem to actually transmit the virus.  We need to know how widespread the virus is in the US population, but we also need as accurate a number as possible.  Currently we have neither.

 

Our children are losing so much of what is important from academic progress to normal socialization and play. If we were to aggressively limit the spread of COVID-19 both by massive testing and contact tracing, but also by some economic restrictions through the summer, then the number of cases would be so low in the fall that the risk of a second wave would be greatly diminished.  Doing what we are currently doing only increases the chance of a large second wave 2-6 weeks after school s  reopen and then they would needs be shut down again, and for how long?

 

 

Plan B is a significant improvement over what we are currently doing and if aggressively applied (with some loss of personal privacy such as tracing apps), it could over the course of a few years reduce COVID-19 to the level that currently exists for polio, ebola and MERS. Plan B would cost about another $3 Trillion beyond what Congress has already allocated. This would both revive the economy and significantly reduce the spread of COVID-19. The economic benefits and the savings in health care costs as outlined in the previous section would more than offset the $3 Trillion.

 

I think Plan C is a better solution, but a good Plan B is far superior to what we are doing, so at least pass CARES 4.

 

The biggest problem with both plan A and B is that we cannot know what our risk is at any given time and most especially, we really won’t know when COVID-19 will end, if ever. This uncertainty causes huge frustration and intensifies the conflict between those wishing to continue restrictions, “save lives” and limit the spread; vs those wanting to “save the economy.”  Even if all restrictions and guidelines are eliminated, many will not be able to participate in the “new” economy.

 

 

Plan C

 

The best solution is to completely eliminate and fully eradicate COVID-19 and any future rapidly spreading virus. If we spent the equivalent of over $5 Trillion to win WWII, then $6-7 Trillion invested in the fight against this more insidious and destructive enemy of all humanity, COVID-19, is a good investment. The goal is total eradication of the virus and the threat that it poses.

Plan C involves a great deal of preparation as well as the recognition that COVID-19 is the enemy of all humankind and therefore we must work together as a worldwide consortium to combat this aggressive enemy once and for all (as well as having a plan for the next pandemic).

Admittedly it is naïve for me to believe that the world can work together. It is not impossible and there have been times in the twentieth century when a level of worldwide cooperation existed.[16]  This pandemic involves very unstable developing countries as well as established economic and military powers. It will mean that the countries that are economically better off will have to contribute more and poor and developing countries will need to be assisted.

The virus requires close proximity between an infected person and a nonimmune person in order to spread.  Even in those countries hardest hit by COVID-10, less than 15% of the population demonstrates immunity. A vaccine that will provide long lasting immunity to most inoculated individuals does not exist and is unlikely to exist in the next few years. If we look at the massive effort that has been undertaken to vaccinate the world against polio, it would take years to vaccinate enough of the US and decades before enough of the rest of humanity is immune.

Shutting down the economy and eliminating interaction between individuals can eliminate the virus in one area. This has been done successfully in New Zealand, so that there are no restrictions, other than all travel into and out of the country is forbidden. Iceland had a robust tracking team that includes police detectives to find all contacts of any case and put them in quarantine. As a result, they only minimally shut down the economy. The management of the pandemic in Iceland was done entirely by the public health department with no interference from any political entity. Large numbers of people have been isolated for 14 days, but there has been excellent cooperation. At the end of 14 days you can go to a restaurant or concert. A special Facebook account for each person in isolation keeps that individual in contact with friends, or even sympathetic strangers.

When a community can supply or store adequate food, then it can isolate from a pandemic, as Gunnison, CO did in 1918-1919; not suffering a single case of Influenza during the two biggest waves.[17]

Currently most countries are controlling the spread of the virus by limiting contact with others.  This puts essential workers at high risk, but a person who stays home except to buy groceries can be fairly safe, especially in countries where everyone wears a mask (Taiwan), or testing is so thorough that it is nearly impossible to come in contact with a carrier of SARS-CoV-2 (Iceland).

Limiting contact with those who are infected is currently not possible in most crowded developing countries (India, Brazil, Nicaragua). Even routine hand washing and hygiene are limited (South Sudan, Cambodia, The Navajo Nation). These issues need to be addressed by developed countries or the virus will spread in developing countries and then return to the developed countries with disastrous consequences.

Currently most countries have a variation on “Shelter in Place.” One only has contact with ones housemates. With large scale testing, a larger groups could isolate together (a village, a city block an apartment building, or even a small town). People would not be stuck in a house, but a “bubble of individuals known to all be negatively tested). If people could isolate in such a bubble and food and fresh water supply for a month were included, the bubble could function for one month with no contact from the outside. To ensure that the bubble is disease free, repeat PCR testing for the virus would be essential and anyone who is positive would have to be totally isolated outside of the bubble (perhaps in a hospital or converted hotel).

The 34 high income OECD member countries already have a cooperative relationship. Together they need to not only continue research on a vaccine, but more importantly manufacture enough testing equipment, supplies, reagents and personal protective equipment for the entire world. They must work together to assure that all people everywhere have access to clean drinking water and sanitation equipment.  This is going on slowly, but COVID-19 makes the need urgent.

 

Once large amounts of testing and tracing of contacts is established, then a way to safely isolate positive cases needs to be developed throughout the world. Then a system needs to be developed that will designate “bubbles” within which people can safely interact with a very minimal risk of transmission. This includes the distribution of protective masks for anyone who must interact with someone outside their bubble in order to get food or be tested.

 

During the several months (hopefully not years) that it takes to get this organized, 60 day food supplies need to be established for each bubble.

 

The entire world will then need to shut down for 60 days. The entire economy will not close, as stores and services can still operate within each bubble. At the end of the 60 days, all known cases of COVID-19 will be isolated and when those individuals come out of isolation, the world will be free of COVID-19 and have a plan in place to quickly circumvent the next virus that crosses from an animal to humans.

 

Yes, this is a Herculean task, but why not just bring this to a definitive end?

 

 

[1] https://www.thebalance.com/unemployment-rate-by-year-3305506 accessed 9 May 2020 and Schwartz ND, Casselman B, Koeeze E;”How Bad is Unemployment? ‘Literally Off the Charts’,” NY Times: 8 May 2020.

 

[2] Scherbina, Anna D., Determining the Optimal Duration of the COVID-19 Suppression Policy: A Cost-Benefit Analysis (March 24, 2019). Available at SSRN: https://ssrn.com/abstract=3562053.

 

[3] Yong E, COVID-19 Can Last for Several Months; The Atlantic, 4 June 2020.

 https://www.theatlantic.com/health/archive/2020/06/covid-19-coronavirus-longterm-symptoms-months/612679/

 

[4] The Week, issue 29 May 2020, page 8.

 

[6] Jarvis, C. I., K. van Zandvoort, A. Gimma, K. Prem, C. nCov working group, P. Klepac, G. J. Rubin, and W. J. Edmunds (2020). Impact of physical distance measures on transmission in the uk, available at https://cmmid.github.io/topics/covid19/current-patterns-transm ission/comix-impact-of-physical-distance-measures-on-transmission-in-the-U K.html.

 

[7] Montanaro D, “Normal Will Take 6 Months or More,” All Things Considered, NPR, 20 May 2020.

 

[9] Scherbina ibid.

 

[10] Scherbina ibid

 

[12] Treasury Direct Archives.

 

[16] For a few years after WWI and during 1946 and to some extent in the 80’s after perestroika there was efforts made at cooperation. The United Nations was supported and the WHO was able to grow, resulting in less disease in developing countries yielding the opportunity for economic growth. The effort to eradicate polio had some initial exponential success.

 

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