
It’s Not Too Late to Go on Offense Against the Coronavirus - ISL
https://www.newyorker.com/science/medical-dispatch/its-not-too-late-to-go-on-offense-against-the-coronavirus
======
tsbinz
> the transmission rate dropped again, to the point where any single case led
> to less than one more. Once that happens, an epidemic dies.

Note that this can take a while. What the article suggests - getting back to
the containment phase - is the stated goal of some countries. However, to get
there quick you need very drastic measures. With the measures we adopted, it
will take a bit of time - I read one estimate that the reproduction number in
Switzerland has been around 0.59 since the lockdown was enacted, so you'd
expect cases to drop by a factor of this per generation - it still takes
weeks/months to go from 1000+ cases to below 100 (where they estimate they
have enough resources for contact tracing).

~~~
dwd
The Australian approach has been fairly good but this virus is persistent.

Once the lockdowns kicked in the doubling rate dropped dramatically and new
case numbers went from a peak of around 500 a day to 10-20 day for a
population 1/10 the US.

From /r/coronavirusdownunder linking the stats with the lock-down measures
gives a good idea of the timeframe involved.

date cases growth doubling

2020-03-21 1071 1.22 3.1

2020-03-22 1352 1.26 3.3 <== 10 days ago, Tom Hanks

2020-03-23 1716 1.27 3.5

2020-03-24 2146 1.25 3.8

2020-03-25 2431 1.13 4.0 <== 10 days ago, overseas self-isolate 14 days

2020-03-26 2805 1.15 4.5 <== 10 days ago, Vic declare State of Emergency

2020-03-27 3179 1.13 5.3

2020-03-28 3639 1.14 6.4

2020-03-29 3985 1.1 7.0 <== 10 days ago, TAS self-isolation 14 days

2020-03-30 4250 1.07 8.0 <== 10 days ago, closing borders to all

2020-03-31 4560 1.07 9.3 <== 10 days ago, rule of 4 square metres

2020-04-01 4864 1.07 11.5

2020-04-02 5136 1.06 13.6 <== 10 days ago, no social gathering

2020-04-03 5358 1.04 15.6 <== 10 days ago, WA,SA closing border

2020-04-04 5552 1.04 18.7

2020-04-05 5687 1.02 22.9

2020-04-06 5795 1.02 28.1

2020-04-07 5908 1.02 33.1

2020-04-08 6013 1.02 38.8 <== 10 days ago, mandatory hotel quarantine

2020-04-09 6103 1.01 46.5

2020-04-10 6203 1.02 52.2

2020-04-11 6292 1.01 60.7

2020-04-12 6313 1.003 69.6

2020-04-13 6359 1.007 83.5 <== 10 days ago, QLD closing border

2020-04-14 6400 1.006 96.5

2020-04-15 6447 1.007 114.2

2020-04-16 6468 1.003 106.9

2020-04-17 6523 1.009 121.1

2020-04-18 6565 1.006 129.2

2020-04-19 6606 1.006 157.3

2020-04-20 6619 1.002 165.0 <== 10 days ago, Good Friday

2020-04-21 6645 1.004 210.6

2020-04-22 6649 1.001 247.4

2020-04-23 6661 1.002 307.7

2020-04-24 6675 1.002 301.3

2020-04-25 6695 1.003 350.7

2020-04-26 6711 1.002 298.7

~~~
donavanm
You should look at the breakdown of cases. I was _very_ worried for Sydney in
early to mid march. What I didnt see until later was the infection acquisition
data. The majority of those march cases appeared to be infected citizens
returning from overseas. Locally acquired infections were only 25% of cases at
the peak. The local infection rate never really hit the scary 3 day numbers.

~~~
gonzo41
Most of the issues in north west Tassie are related to the Ruby Princess,
which is just a massive scandal that hopefully we'll learn from in the future.

~~~
donavanm
Oh no doubt. The handling of the cruise ships seems to be a fiasco. Will
definitely look forward to a future report on the matter.

~~~
dwd
Most cases were confined to clusters, and many of those originated from
someone coming off a cruise ship.

At the moment they easily have the resources to track down every case quickly,
and with a million people signed up to the app that should get easier.

------
tomohawk
> South Korea, which so far has managed the pandemic better than any other
> country

Actually, Taiwan has done better. They've had no local cases for 14 days.

[https://taipeitimes.com/News/front/archives/2020/04/27/20037...](https://taipeitimes.com/News/front/archives/2020/04/27/2003735362)

They did it by ignoring the WHO's advice and locking down early and then
aggressively containing all cases, preventing a general outbreak.

They've been pursuing this since December 31st, when they issued a warning to
the WHO about what was going on and locked down. The WHO ignored them.

[https://www.taipeitimes.com/News/front/archives/2020/04/12/2...](https://www.taipeitimes.com/News/front/archives/2020/04/12/2003734453)

They've taken 4 months to get to no new cases. From a much better starting
point. With a much smaller population.

I'm very skeptical about what this guy is advocating.

~~~
senderista
One difference is that you can't say the word "Taiwan" in places like the WHO,
and this guy may have been afraid to for similar reasons.

------
aphextron
It's absolutely depressing knowing that this all stems from a complete utter
lack of leadership at the federal level. That states are having to implement
their own policies and plans of attack for this virus is a total travesty.
Massachusetts is undoubtedly leading the way here. But this is a _global_
pandemic, that can only begin to be approached at the national level. With our
society's level of interconnectedness, state level interventions are
completely meaningless.

~~~
sandworm101
>> That states are having to implement their own policies and plans of attack
for this virus is a total travesty.

Blame the constitution. In the US system of government health is largely a
state matter. Setting aside trump, the federal agencies just aren't setup to
lead. They can issue statements and guidelines but lack any actual authority
on the ground. State governors have the power, but even then they cannot boss
corporations around (hospitals/insurance companies). They cannot even divert
masks from one hospital to another, let alone demand that a patient be moved.

Now in other countries, the ones with government-provided healthcare, the
national government has real authority. They can directly order policy
changes. They can close individual hospitals and/or move patients. They can
control the flow of equipment because they are the ones paying for that
equipment. Canada just deployed soldiers _into some care homes_. It took less
than 24 hours without any new legislation needed. A US state governor might be
able to use the local national guard, but deploying the army within the US?
Into a privately-run care home? That is a power trump doesn't have.

~~~
stormbrew
In Canada health is constitutionally devolved to the provinces. Explicitly,
since our constitution was actually written in the last 40 years so was
written with the awareness that health care is a major government concern.

In so far as the federal government sets health policy, it does so through the
carrot and stick of federal funding through equalization and other programs. I
am reasonably certain that this is also an approach the US federal government
has used in areas of devolved authority (particularly education).

And looking at the specific situation you're talking about, it appears the
Ontario government requested military assistance, and it was granted, not the
other way around.

The US federal government may not have explicit authority, but the idea that
it is absolutely helpless to coordinate efforts among the states (aka
interstate commerce) seems kind of blatantly absurd. Never mind that they seem
to, in fact, have done quite a lot of diverting masks from where they were
going to elsewhere already. Just you know, not in a helpful way.

~~~
sandworm101
[https://en.wikipedia.org/wiki/Posse_Comitatus_Act](https://en.wikipedia.org/wiki/Posse_Comitatus_Act)

Domestic use of US soldiers, even with a state request, is not a simple
matter. Trump wanted to deploy troops along boarder --> no go. Federal troops
cannot be used to implement domestic policy. New York probably couldn't get
troops if it asked.

Canadian troops, if asked by any level of government, can deploy domestically
and do so regularly. That's the advantage of a single sovereign authority (the
crown). Everyone is literally on the same team.

The US fed exercises its health power indirectly, through spending. It can
demand that certain hospitals, those that receive federal funds, act in
certain ways. But it cannot dictate treatment regimes. (This fed-state split
on health has been heavily influenced/reinforced by the abortion debate.)

------
Animats
This guy has an impressive track record. Read what he has to say.

~~~
lnsru
It’s totally different than agenda in Germany. Heads in the news can’t stop
fantasizing about herd immunity. And this guy has a plan what to do right now.

~~~
neuronic
Nobody is taking the approach of herd immunity except some political figures
who try to gain from the crisis (Armin Laschet, CDU, in particular).

~~~
redis_mlc
Actually, I am. Are you planning on lockdown until 2022?

~~~
_ph_
We don't need a lockdown. We only need to have enough hygenic protections in
place to keep the infection rate low. With sinking infection count, the
infection rate drops to zero in many places - you do need to have contact with
an infected person to get infected.

Good hand hygene and wearing masks and keeping distances in most places go a
long way towards preventing infections. Events like the Oktoberfest and other
gatherings of thousands in direct contact might be cancelled for undetermined
time, but the rest of the life can continue.

~~~
lnsru
With <100 daily new infections probability to successfully trace the source
and check all contacts and eventually quarantine them is very high in Germany
for sure. Might take a while, but there is no other real way.

------
LatteLazy
Um, the author is relying on three things, none of which seem reliable:

* that anything China claims is true, so far they've been lying constantly, we know this.

* that we will be able to accurately contact trace. This is problematic because its easy to tell who I have had contact with. But it's much harder to tell who has used the same door knobs or shopping trollies that I have. It's also an exponentially larger number. You can quarantine the 50 people I've touched or spoken to in the last week, you can't quarantine the 2000 who went to the supermarket the same day as me. Not without just quarantining everyone anyway, so why bother contact tracing?

* that I can be isolated if I am not sick. Imagine if your housemate got the disease, with proof via testing. Now what? You can't leave the house for 2 weeks? Good luck surviving off whatever is already in your cupboards, it's hard enough to keep people from doing things they shouldn't under social isolation, but mass house arrest is unenforceable, at least in the west.

Also,the author perpetuates a myth that's risen about social isolation. Let's
clarify: The plan is NOT to keep everyone locked away until the case count
actually reaches zero, that will never happen. The plan is to work out how
many infected people we can cope with at a time.

If you have 25k ventilators, and 5% of patients need ventilation then you know
you can have 500k people get the disease simultaneously. That way, the
mortality stays at the minimum rate because everyone who needs treatment can
get it. Any higher and you have to ration ventilators and the death rate
spirals.

So we will aim to have a certain number of people get it at a time. If we drop
below this number, we will relax social distancing somewhat, maybe reopen
schools or permit some use of restaurants in order to INCREASE transmission.
But then reverse that when the infected load rises.

This is the real reason testing is important. It's irrelevant whether you have
the disease, it's very important to know how many people have it (especially
how many people have it now and will need treatment in 1,4,7,14 etc days).
Tests should be used for population monitoring not individuals. This was a key
error from day one that is still happening today. Whatever your condition, YOU
do not need to be tested.

Eventually we will develop a herd immunity which will gradually allow more and
more openness without increasing transmission rates. Until one day so many
people have had it that no measures are needed to keep the rate low enough to
deal with. That's when we return to normal.

There are nuances to how we do this. High risk groups should remain more
isolated for longer as they are more likely to die or need ventilation. We
need population testing, something governments are stubbornly refusing to do.
We don't know transmission rates under various levels of lockdown. All this
needs to be managed semi-locally, so London might be opening up while Cornwall
remains closed.

This approach is clearly laid out and was at the beginning of the current
measures both academically and generally.

This is about control, not eradication, because eradication is not possible.
Any attempt at eradication will fail when we're unable to find literally every
case world wide, we relax quarantine and then suddenly it rockets back in.

As soon as the author started talking about eradication, he left the
scientific concensus. As soon as he claimed we could return to normal life if
we got contact tracing working, he made a claim with no evidence to back it
up. Contact tracing is a nice to have, but not important. The important things
are healthcare capacity (aka ventilators) and population monitoring.

~~~
twic
> As soon as the author started talking about eradication, he left the
> scientific concensus.

Something i have read is that there is a split between epidemiologists and
public health experts. Epidemiologists accept that we can't eradicate, and so
have to manage the outbreak. Public health experts still think in terms of
eradication.

My understanding is that this is an inertia thing. Public health experts have
spent decades focused on eradicating diseases, so that's the only way they can
think. Meanwhile, epidemiologists only study diseases that have escaped
containment, so that's the only way they can think!

~~~
LatteLazy
Thanks, that makes sense, and that's exactly what I felt the author was stuck
on. They've spent decades trying to eradicate diseases (TB and HIV), so now
they want to pursue another eradication program. It's attractive, I get why.
But it's not applicable to a disease we can't cure and one with rapid
gestation transmission.

It's somewhat ironic that this expert's own expertise is what stops him from
listening to the real experts...

------
theredbox
Korea (KCDCD) basically says that covid19 will be seasonal.

------
throwaway888abc
Pragmatic article.

"This is a disease that will be circling the globe for a long time. The virus
could very well become seasonal, like the flu—and, like the flu, it might
mutate regularly, making it a moving target for vaccine researchers. Without a
durable system in place, we may find ourselves trapped in a cycle of lockdown
and stimulus, waiting and hoping, with no end in sight."

~~~
drran
Or we will figure out how to make vaccines faster, much faster, faster than
any virus can mutate.

------
axaxs
It sounds like a good plan, but I can't see it working here. USA in general
has strong individualism, I guess it's called. Basically the idea of look out
for yourself, and screw everyone else. It's why you still can't buy paper
products, why we don't have universal healthcare, why we have so many
homeless, etc. Heck, I remember when cases first started in KY, at least two
people defied orders to quarantine even after testing positive, to the point
they sent police to keep them indoors. There's no way enough people will self
quarantine to make this plan effective. Now, if you can somehow force
quarantine people, we'd have a fighting chance, but that makes a lot of people
uneasy, perhaps rightly.

~~~
SpicyLemonZest
I don't know if "screw everyone else" is fair. It's the idea that living
freely is a sacred value; that we won't and shouldn't take the path of the
fewest deaths, if that path leads to a society we don't want to live in.

That's not to defend people who actually have the virus breaking quarantine.
Limited quarantines have always been compatible with freedom, that's just dumb
selfishness. But if the proposal is that the 30k new infectees a day* and all
their close contacts should be forced out of their homes into quarantine
camps, yeah, that's not going to work here.

* I know the real number is likely much higher than this.

~~~
pjc50
> if that path leads to a society we don't want to live in.

1-2% of people will be unable to live in the unquarantined society due to
dying, and a significant number more may never fully recover. It's more "live
free AND die".

~~~
SpicyLemonZest
Sadly, yes, a free society sometimes demands a heavy toll. We should try our
hardest to find ways to bring that number down, and when this is over we
should work hard to improve our response tools so the price of the next
pandemic isn't so high.

I think you may be misunderstanding my perspective. When someone proposes
remote quarantine of all contacts of 30k/day infected cases, or shelter-at-
home for the next year, I react as if they said "forcibly infect everyone
below 65". If you sit down and do the math, sure, these policies will
significantly decrease the death rate below the baseline of an uncontrolled
pandemic. But they have the critical flaw that they're weird authoritarian
control fantasies, which fail to respect the general public as anything other
than bodies which must be optimized for their own good.

------
redis_mlc
> the transmission rate dropped again, to the point where any single case led
> to less than one more. Once that happens, an epidemic dies.

Unless, you know, it's as contagious as corona. Then it only takes one person
to infect an office or grocery store or hospital (as happened with SARS-1 in
S. Korea.)

I wish people would start using facts, instead of hope.

~~~
lutorm
What do you mean? That statement is manifestly true. _IF_ any single case
leads to <1 additional case, then the numbers will decline. That's math. One
person being able to infect an entire office just means it will be harder to
get to that point.

~~~
KMag
More succintly: In the SIR (Susceptible, Infected, Resolved) epidimic model,
r0 is the ratio of dI/dt / dR/dt. r0 < 1 means people are recovering at a rate
faster than new people are getting sick.

If each new case, on average results in less than one new case, and all cases
eventually resolve (recovery or death), then it's a mathematical truth that
the number of active cases must go down over time. The decrease isn't
necessarily monotonic, but over a long enough time frame it's inevitable. The
bursty nature of super-spreading will produce variance, but as long as these
super-spreaders are accounted for in the observed r0, the variance itself
doesn't change the long-term outcome.

Now, the estimated/measured r0 is just a sample/estimate of the (unknowable)
"true" r0, and r0 isn't constant, but those are separate issues.

