Coming Out of Coronavirus Captivity
by Sam L. Savage
We have met the enemy and he is us.
The symptoms of COVID-19 range from not even knowing you have it to a death sentence, depending on the patient. Writing on this disparity in the Atlantic, Dr. James Hamblin says that COVID-19 is “proving to be a disease of uncertainty.” He quotes Dr. Robert Murphy, an infectious disease specialist at Northwestern, who was in the trenches of the early HIV epidemic.
“As Murphy puts it, when doctors see this sort of variation in disease severity, ‘that’s not the virus; that’s the host.’” Apparently the virus can make some people’s immune systems have a panic attack called a cytokine storm. This can be brought on by a number of diseases and other conditions, but because the body is fighting itself, it’s tricky for medicine to know whose side to take, and it is often fatal.
Graphic from The Conversation
Of course, medical science has made huge strides since 1918 (the year of the last big pandemic), or since 2018 for that matter, which we hope will help with COVID-19. In a recent article in the Economist on Learning to fight the next pandemic, Bill Gates points to recent “giant leaps in vaccinology.” In particular, he cites mRNA vaccines that teach your body to create its own immunity, rather than injecting antigens for your immune system to tussle with. He identifies two other relevant areas of medical advances: diagnostic testing, which is our ultimate gauge of pandemic control, and antiviral drugs, which will reduce the impact of contracting the disease.
Update
These uncertain developments may take months or years, but there are also uncertainties being resolved day by day, that shed light on the pandemic. On March 26, 2020, which seems like a lifetime ago, I posed three questions about COVID-19 and wondered if they would be resolved in upcoming weeks. My questions then, and what we have learned about them in the past month, appear below.
What percentage of the total population has been infected?
As of my March blog, I had only seen statistics from sick people (a biased sample, which underestimates the total). What do we want today’s total infected to be? 100%, of course. If we all had the virus, we could just go back to our work and play. Furthermore, it would imply a lethality rate comparable to infected hangnails. But 100% of us have not been infected. The good news, however, is that recent studies show that the percentage is perhaps 50 times larger than indicated by the previous studies on symptomatic patients. The New England Journal of Medicine reported on April 13 that of 215 women who delivered babies in two New York hospitals between March 22 and April 4, 15% tested positive, and over 80% of those were asymptomatic. The bad news is that 15% is way below herd immunity levels. But these results, if they are applicable to the general population, show a vast reduction in the effective lethality of the disease.How badly will our healthcare system be overwhelmed?
Back in March, the worst had not hit, and there were visions of one giant wave of infection crashing across the country, swamping every ICU and ventilator at once. The lethality increases by perhaps an order of magnitude if you are really sick and there is no room for you in an ICU. Now we see that both the timing and intensity vary by geography, allowing the mutual sharing of resources with the ebb and flow of the contagion across regions. The ICU problem is now being mitigated with time and money. And I would like to put in a plug for combat pay for our healthcare workers on the front lines, our most valuable resource, who are being disproportionally impacted.When will we develop a test for antibodies?
Was I really asking this only a month ago? Antibody tests are all over the news today. However, you need to read the fine print. For example, one such test warns that “Positive results may be due to past or present infection with non-SARS-CoV-2 coronavirus strains, such as coronavirus HKU1, NL63, OC43, or 229E.” The New York Times has a good podcast on the current state of both diagnostic and antibody testing, but stay tuned, as things in this area are evolving fast.
Furthermore, according to the World Health Organization, having antibodies does not necessarily provide immunity. However, with such widely varying outcomes from the disease, having antibodies at least proves that if you catch it again it won’t be your first rodeo, and that you did pretty well in your last one.
Getting Back to Work – An Unstable Equilibrium
There is now a healthy debate about the risks to the economy of staying shut in too long vs. the risks to our health of opening up too soon. We won’t just make a single decision as a nation and charge ahead regardless of outcome, but instead we will monitor the situation location by location and adjust as needed. But controlling a pandemic is not a stable equilibrium, like driving a car that tends to go straight when you let go of the wheel. It is unstable, like balancing a broomstick on your hand. You must continually monitor its motion, and if it falls over it will rekindle the pandemic. Furthermore there are three additional complications. First, there are many brooms, and if you let one fall over it may spread infection to the others. Second, the positions of the brooms are monitored by clinical testing and contact tracing, which we are still not set up to carry out on a large scale. Third, instead of observing the positions of the brooms, we are seeing a delayed video of the positions, because it takes a couple of weeks for new infections to show up. In short, we don’t know how it will turn out.
My Next Questions
Below are three more questions I hope we get answers to by next month.
How will the economy opening experiments go?
Different experiments are being tried in different countries, states, and geographic regions and there will be both health related and economic lessons from each. In particular, Brazil’s relaxed approach and those of Sweden, Denmark, and New Zealand, as described by the BBC, are worth watching. Who will be successful at balancing their broomsticks? And when some inevitably fall over, how big a second wave will they make?Do antibodies make us immune?
Hopefully in a month we will have a better understanding of this issue. Depending on what we learn, we may be able to offer immunity passes for people to head out into the world again.New therapies
Two things have moved in the right direction since March 26. First, we continue to build our ICU capacity, and second, due to the higher background prevalence of COVID-19, the lethality is less than we first thought. Now imagine that through survivor plasma, some new antiviral drug, or a way to treat cytokine storm, we further reduce the lethality while continuing to grow our capacity. Might we reach a tipping point at which could open the economy much faster? We are not there yet, but what will things look like in a month?
In March I wrote that demonstrating some control over the pandemic would be rewarded by the financial markets. Since then we clearly have been able to flatten the curve by hunkering down, and in the last month the Dow has risen about 10%. That would be great in normal times if that’s any comfort.
But just as uncertain as COVID-19 are the economic impacts of shutting in. The next month will reveal much in this area as well, hopefully enabling us to make better econopandemic decisions than than we can now.