What we knew we should have done about Covid, and we didn't
3 months into lockdown, and more into the pandemic, the front page article in the San Jose Merc described 8 things we got wrong at first Some of the list is right, and a few of them are dangerously wrong, but I want to focus on something else, namely the things we got wrong even though we (or at least many of us) knew better. Things we have little excuse for getting wrong, particularly because others got them right.
Not putting immense effort into testing
The most obvious and deadly error was not putting all effort into producing tests and distributing them as widely as possible as quickly as possible. Other countries cut off their outbreaks quickly doing this. Some of the things that went wrong were:
- At first, all testing had to be done at the CDC. Almost no tests were done.
- Even after that ended, tests were rare enough that only people who met a very high bar -- contact with people from Wuhan, strong symptoms got tests.
- The lack of testing caused both under-reporting of extant cases, and a poor estimate of the case fatality rate.
- Even later, as better tests were developed that did not require an unpleasant nasal swab, such as a saliva test, the FDA got in the way of their deployment.
Not putting immense effort into study of the means of transmission
We've learned things about the means of transmission very slowly. We're even still uncertain about a few of these:
- What fraction of cases never show symptoms and can they transmit it?
- When are presymptomatic people infectious?
- What is transmission risk of various outdoor behaviours vs. indoor ones?
- How much do masks reduce transmission, and which types of mask?
- What are the transmission rates for housemates, strangers and near contacts?
- How much transmission is via superspreaders? (Some research suggest it's a lot)
- What are the risks for indoor office work or factory work? Protests marches? Outdoor dining? Indoor dining? Eating food cooked by an infected chef or served by an infected waiter?
- How much transmission is there from surfaces and what surfaces?
- Do children (who are less affected) also transmit it less?
- Do seniors (who are more affected) also transmit it more?
- What are the specific comorbidities? What drugs and supplements reduce acquiring infection? (There is good research on which ones reduce case severity but could be more.) Do any substances reduce transmission?
We're slowly learning some of these things, but slowly. At first, before we knew much at all, strong lockdown was our only clear path to be sure we were going to reverse the exponential growth of the virus. But lockdowns are very expensive, and once you know more about transmission, you can start relaxing them, relaxing the things you learn are lower risk. Which means every day sooner we learn those facts is a day sooner you can open those activities and the result can be billions of dollars of economic activity.
If we knew these things we could make scientific decisions about what to do about protest marches or outdoor dining. We could know what types of offices can open. We would know what can open if you wear a mask, but not open if you don't.
Which means there should have been as much money as needed, and more. to research these questions around the world. And we knew we wanted it, and some researchers went to work on it, but they were never given the tools they need to do it fast. Tools would include:
- Huge budgets and access to researchers
- Laws to compel disclosure of certain types of useful data
- Contact-tracing apps, not just to track possible infected parties, but to be able to know what types of contact resulted in what rates of transmission. These apps could have been given to volunteers, with minimal privacy concerns. We need privacy protection in general contract tracing apps, and we've been spending a lot of time trying to get that right -- but we don't need to do that for a volunteer data gathering app.
- Global efforts to quickly study the different effects of all the many lockdown rules -- and de facto lockdown practices and non-observances -- in all the cities of the world. Without planning to, the cities have created a giant laboratory of experiments which we failed to exploit at anything but a slow scale.
The key to a lockdown is to get the virus spread rate (the base of the exponential equation ) known as R0, down well below 1. For example, if you get it to 0.5, and the virus runs that in 5 days, then in 25 days you can get the virus down to 1/30th the size, after which you can inch the R0 up towards just below one, where it is present but not growing. Or you can keep up the strong lockdown and kill it even more, but either way, you find the fastest path to re-opening. You can't let it get much above 1.0 or it starts growing again. At least until you have a treatment or vaccine.
Research with willing test subjects
Normally, researchers are trained not to do research which puts experimental subjects at risk. However, it is OK to study what happens to people who voluntarily place themselves at risk.
Pretty early on it was clear that there was a large population who did not want to lock down. They eventually came to defying the lockdown, even protesting in the streets for the right to defy it. There is no question they wish to expose themselves to risk. The problem, of course, is that the lockdown is not to protect them, it's to stop them from being vectors who breed and transmit the disease to the vulnerable.
An opportunity was missed to make use of this enthusiastic consent. A lockdown is still workable when some people are given an exception to it. You just can't give the exception to everybody or you get exponential growth again. The lockdown rules always gave an exception to the so called "essential workers" who provided necessary services. It would also be reasonable to not lock down a group of people who demand to go about normal lives and constantly wear data gathering devices and be subject to regular testing. While it is not ethical to do an experiment which pushes people to take risks, it is very acceptable to ask subjects to wear recording devices and yield some privacy in exchange for a reward. The reward being to be treated like an essential worker. (Actual essential workers could also consent to this data tracking.)
To be clear, encouraging people to take risks for science would not be ethical. Asking them to collect data when they take the risks they keenly want to take is not. It is the lockdown law which holds them back from what they want, not being outside the test group.
There would have to be some caveats on participation:
- All members of the household would need to consent to a person's participation (if not an essential worker already,) particularly older members. With consent, the entire household would probably become subjects together.
- Companies which wish to re-open in this fashion would need full consent of any employees joining them, and we need some way to assure that the pressure of "not getting laid off" is not used to push employees into taking risks they don't want to. For low-skilled jobs, it will be necessary to use other volunteers who don't work at an open business and train them. This works fine for things like restaurants, shops etc. but not for specialized work. However, it is not necessary to study every type of work.
- Typically, only a small subset of any type of business would open, because only a small set of customers will be able to come. If 10,000 people are study subjects, you can only open enough restaurants to serve those 10,000 under normal circumstances.
- Businesses which deal with the public would have to verify that all customers are in the program, probably using the tracking app they are required to carry at all times.
- At-risk people and their housemates would not qualify. This would reduce information on whether reception of infection is different for the at-risk, that must be learned another way.
- Chances are this would only be done in a few towns, the towns where the volunteers are most insistent at volunteering. It would also be done in different countries, particularly places with differing lockdown rules.
- All volunteers would be given extensive education on the risks to assure consent is informed as well as enthusiastic.
With tracking devices (bluetooth, GPS log and body cam) almost every person to person transmission would be detected. It would be harder to detect transmission via surfaces or ambient air, but the body cam would reveal what the subject touched (outside their home) during the likely time of infection.
Such precise data on all transmissions would give us much of the data we need to fine tune the lockdowns for maximum virus prevention at minimal economic cost. It would save huge numbers of lives, and untold billions of dollars. It's hard to think of anything with bigger payback.
As noted, all subjects would get regular testing. If infection were found, they would naturally go into isolation. There would be superb contact tracing both to find the source of their infection, and to warn and isolate any contacts during their infectious period. With saliva based testing and group testing, testing could be done twice daily to result in minimal transmission. That's actually not ideal from a research perspective -- this group will be much safer than the public due to this testing -- but it is of course necessary from an ethical perspective.
We actually had reasonable data that masks are effective early on. Masks are simple and cause no economic hardship, so it is unclear why they were not required early -- other than of course, that there were shortages of them due to other mistakes.
Not clearing the senior homes
It was immediately clear back in January that older people were at the most risk. It was obvious that the fastest path to saving lives would have been to get people out of the senior homes if we could, or to improve procedures in them. A large fraction of the 110,000 deaths so far in the USA came to seniors, and we've spent untold billions trying to reduce that total -- but we could have reduced it a lot with much less than billions.
Not already being practiced at all of this.
We've known some pandemic was coming for decades. Bill Gates and many others warned of it and didn't listen. I warned about how tech like videoconferencing could make it more tolerable in 2005 but nobody prepared. We could have prepared, and been ready to reduce the economic impact a lot.
Not realizing the public just won't get non-linear thinking
Sadly, too many of our intuitions are linear. People looked at low, but exponentially growing case numbers and figured there was little to worry about.
What we should have known
There are some things that were less clear and perhaps it is hindsight that makes us realize we should have known them
The public will only tolerate lockdown for so long
It was not clear when lockdowns began that there are things which, even if they are the right medical choice, the public, and even the government officials, will not do. Fatigue sets in, and they will start taking reckless risks with their own lives, and the lives of others.
This may mean that it's better to do a hard lockdown for a shorter period, to reduce fatigue, than to have a lesser lockdown for a longer period, even if the former choice is worse for other reasons. The long lockdown is simply not on the table short of a police state. At least in the USA.
It will become a political issue
Fatigue over lockdowns is universal, but it and many other factors became political issues, and people's views on scientific and medical questions have now become driven by their political biases. Those biases are also affecting what research they read and believe, so they (I) feel that they are making all their conclusions only through rational scientific analysis. But nobody is.
It became a tool of international conflict
Just as Russia interfered with U.S. elections in its efforts to disrupt its rival, it is likely they are also interfering via social media with the virus situation, to increase the polarization and politicization and drive people towards more chaos and more wrong decisions. Even though we were shocked when it happened in elections and vowed never to be surprised again... we seem to have been surprised again.