On April 17 — seemingly a long time ago — I wrote about what steps would have to be taken in order to (cautiously) “reopen” US states from their various lock-downs and stay-at-home advisories.
The piece tried to focus on the “how”, versus the “when”.
By the early days of May, most states had begun re-opening, and now all 50 states are well along in the process. So how are we doing in terms of following through on the actions that we know can mitigate the spread? What can we expect in the next few months? How should we behave?
This follow-up piece will be divided in the following sections (I have been told I try to cram too much into everything I write, with excessively long sentences, such as this one: I am hoping making this a bit more structured might make easier to follow my writing. Fingers crossed.):
- “Second wave” concerns.
- The importance of communication, compliance and behavior modifications in beating the pandemic.
- Public Service Announcement.
“Second Wave” Concerns
Medical Definition of “Second wave”: A phenomenon of infections that can develop during a pandemic: the disease infects one group of people first. Infections appear to decrease. And then, infections increase in a different part of the population, resulting in a second wave of infections.
Public health officials and policymakers are concerned about a “second wave” of the pandemic hitting, potentially with even greater force than the first. Most are focused on a timeline towards the fall / end of the year. Some of the (justified) concerns are centered about a renewed surge of COVID infections coinciding with a flu season of unknown severity, taxing healthcare systems even further. That would be bad news for sure.
Yogi Berra: “It’s tough to make predictions, especially about the future.”
Here is the really bad news: in my opinion (and being mindful of the quote above), we are going to see a continuous, substantial increase of infections and fatalities in the US starting (very, very roughly) early / late July, if not sooner. Quite likely, by August / September we might revisit the peaks of daily confirmed infections and fatalities we saw in April.
What am I basing such a pessimistic forecast on?
This bears repeating: this is a very infectious, new virus that spreads at an exponential rate. Please re-read my previous Timmerman Report articles discussing R0 and the rapid spread of the virus. I am still absorbing the visual shock of the historical New York Times front page for Sunday May 24, which listed names of roughly 1% of the dead across the US, in a stunning display covering several pages. I spent hours on its interactive version on the website. Scrolling through it, I was reminded that the total US death toll from COVID-19 was about 100 on Mar. 17. We are now on track to exceed 100,000 deaths by early next week, just as we are “re-opening”. It is easy to forget that.
Let that sink in for a second: 100,000 fatalities in two months.
Let’s also keep in mind that, as of right now, only / roughly a few percentage points, if that, of the US population has been exposed to the virus. Exposure rates appear to vary greatly from state to state, of course (with NY likely being the most exposed): that said, I would be personally shocked if it turns out that more than 3-5% of the US has been exposed as of right now. The problem is we will not know that for sure for a while yet.
For those of you who think this virus will stop circulating altogether over the summer: I would like to point you towards the rapidly escalating pandemic in South America, particularly in Brazil. Rio de Janeiro has had temperatures in the 60s-70s degrees Fahrenheit for a while and cases have spread very fast there for weeks now. Yes, we should expect some R0 reduction (driven by higher humidity, sunlight, etc.), but again it will not magically disappear.
Another important statistic: back in March, two-thirds of US newly-confirmed cases were concentrated in just five states: NY, NJ, MA, CA, IL. The rest was mostly in MI and WA, which were also hit early (and very hard in the case of MI). Those states reacted early and with the strongest distancing guidelines and measures. At great economic cost, for sure. But they saved lives.
Last week, two-thirds of newly confirmed cases came from the other 45 US states: the virus has continued to spread widely across the country during those two months.
It’s not “just a New York thing” because the city is dense and has subways. It is accurate that highly dense urban areas were hit first and (so far) hardest, and that high population density “weaponizes” the virus. But other, less dense and even rural areas of the country are not “immune”. There is no existing immunity. The virus will keep spreading.
If we do not beat this virus everywhere, we won’t beat it anywhere.
Also an important contributor to my pessimism: since the virus started spreading in Jan / Feb in the US, we did not ramp up PCR (nucleic acid) or serological (antibody) testing to a sufficient scale to identify early on asymptomatic / symptomatic infection spreaders and thus limit the reach of the virus. There is an understandable supply scarcity of reagents needed to perform the tests at a scale that few previously imagined. In addition, a number of antibody tests have been faulty (to the point of being useless).
That said, a country with the technological prowess of the US should have figured this out months ago. We did not.
The importance of communication, compliance and behavior modifications (non-pharmaceutical interventions) in beating the pandemic
A final component leading me to my pessimistic predictions: there is no way we can beat this pandemic without clear, transparent, coherent communication by authorities, followed by the citizenship’s broad compliance with behavior modifications to reduce transmission. Assistance from drugs and (hopefully, one day) safe and effective vaccines will come, but we need to limit the damage and survive before the cavalry arrives.
Needless to say, almost all of those components are missing or confusing at the very least. The sacrifices of so many healthcare and other essential workers and the many people sheltering at home away from their families are potentially being squandered when a minority of the population refuses to comply. When enough come together in close proximity indoors, the math clearly shows that it increases the risk of “super spreader” events like the choir practice group in Skagit County, Washington.
As I am sure you have seen on the news from Memorial Day weekend, multitudes of people have celebrated the “end” of the lock-down and the long weekend by frolicking in large assemblies in swimming pools, beach town sidewalks, across the US. No masks to be seen. Social distancing nonexistent. This is unconscionable.
I want to express just how important those non-pharmacological interventions are by discussing briefly the Japanese experience and making a “compare & contrast” exercise between theirs and other countries’ response to the pandemic.
Japan has surprisingly managed to avoid a catastrophic outbreak, contrarily to most pundits’ predictions. It has the oldest population in the world, with very densely populated cities, and large public transportation networks used by most citizens. It also has very extensive travel links to China, so it is impossible to think that it was not seeded early in the pandemic.
Japan did not perform mass testing of its citizenship, like South Korea, nor did it impose restrictive lockdowns (hairdressers and restaurants have been kept open: for those who know me, I do care way more about the latter than the former, but not everybody is as follicularly challenged as I am). According to Worldometer’s dashboard, Japan has had only ~800 fatalities to date due to the virus. This is a miracle that cannot be overstated and that everybody is quite puzzled by.
Very early on (in late January), Japan activated its public health centers, which are heavily staffed with nurses trained in contact tracing. So, no fancy contact tracing app like Korea or Singapore, but old-fashioned shoe-leather epidemiology performed by an army of well-trained individuals. People with suspected symptoms, or in contact with people with suspected viral infections, were first screened for other respiratory viruses (influenza, RSV, etc.) and only if tested negative, were then tested for COVID, maximizing the use of scarce COVID test resources. Quarantines of infectious clusters were also sensibly put in place, like in Korea.
A huge emphasis was also put on behavior modification of the entire population to minimize infection spread: preventing one cluster of patients from creating another cluster.
To that extent, government and health authorities spread early, broadly and effectively a very simple message: “avoid the three Cs!”: 1) Closed spaces (with poor ventilation), 2) Crowded places (with many people nearby) and 3) Close-contact settings (such as close-range conversations).
Those recommendations are so sensible — and easy for people to remember — that there is no need, hopefully, to elaborate further. That said, they were given very prominently, very early, and very clearly, by the entire government apparatus as a single voice.
Finally, and essentially, the population broadly complied. Everybody wears masks at all times when walking outside. Nobody speaks loudly (or at all, actually) on their phones on subways / other means of public transportation / while walking down the street (yes, that was already the case in Japan even before the pandemic: I am hoping to sneak in some permanent behavioral modifications also in the US for after the pandemic).
There are probably other factors helping protect Japan from the worst. The population has arguably the lowest rate of obesity and diabetes in the developed world, but again that should be counter-balanced by the demographic skew towards elderly citizens. Who knows. But I am sure there are lessons to be learned here. And that you, non-mask-wearing runners in downtown residential Boston, should learn (that is where I live).
- Testing at scale would be very useful to contain the pandemic: in the US, we do not have large volumes of tests available yet;
- We could compensate for the lack of large-scale testing with a skilled contact-tracing infrastructure, thus reducing the spreading from one infected cluster to the other: in the US, we lack enough trained people; a tech-based solution is not available yet and might run into privacy and implementation concerns;
- We could have tried / try now to compensate with the issues in 1) and 2) above by implementing a sensible communication policy. Communication of the risks / benefits associated with each behavior, if implemented early, clearly and spread widely to ensure compliance, has shown benefits. It is clear to me that the communication effort in the US should probably be characterized as late, lackadaisical, and lacking in consistency and clarity across the various branches of government and public health policy agencies. There are now many instances, across a number of US states, of mistaken statistics provided to the public, concerning both testing volumes (confluence of PCR and serological testing) and undercounting of cases. Ruth Etzioni had another great piece in Timmerman Report about this recently.
Public Service Announcement (Part I)
First, a preamble: this gets into some cultural aspects that might be controversial. You might want to skip this next section if you find it disagreeable and go to PSA (Part II) with some more concrete suggestions. Those should be objectively useful, I hope.
According to the CDC, 45% of the US population has pre-existing conditions (diabetes, hypertension, obesity) that appear to increase severity and fatality outcomes when infected with the virus. This will certainly worsen the already dismal count of blood and treasure (or lives and livelihoods) that the country will have to disburse to get on the other side of this pandemic.
What I would like to discuss, and I am on very thin ice here, as I am a guest in this amazing country, is the role of pre-existing convictions in increasing infection spreading. A number of people in the US reflexively dismissed, early on, warnings coming from science journalists and healthcare / government about the virus. Some of that, certainly early on, might be based on partisan positioning, some of that might be due to a narrow / misguided interpretation of the “American exceptionalism” that seemed to think “it can’t happen here, because nothing like this has in anyone’s living memory.” (I want to state for the record that I do truly believe that this is indeed an incredible country). It might be also hard for people to truly understand the implications of a tragedy that has not yet affected them / their region. However, the virus does not care. It follows a biological imperative to reproduce and spread itself.
Equally, we need to face this pandemic as a challenge for us as a species, not as something to face as a jigsaw of disparate strata of society (or regions) with different socio-economic status, education, access to healthcare, etc. Again, the virus does not care. You should. Your behavior affects others. They might be more or less privileged than you, might be younger or older, it does not matter.
Let me briefly introduce Ayn Rand, celebrated author of “The Fountainhead” and “Atlas Shrugged.” Rand was the founder of a philosophical system named Objectivism (which I am not going to get into, but let’s say succinctly she was not the biggest champion of socialized medicine or collectivism, and she’s become a kind of hero to modern libertarians in the US).
Even Rand, skeptical of the role of government and a champion of individual rights as she was, discussed pandemics as situations where society (as a whole) needs to respond together for the benefit of the herd versus the narrow benefit of the individual. According to Rand, knowingly or negligently subjecting another person to infection with a deadly pathogen falls under the category of the initiation of physical force (like dumping toxic waste on another person’s property).
She makes the illustrative example of “Typhoid Mary,” an asymptomatic carrier of a typhoid fever. She was released from quarantine in 1910, but repeatedly broke her promise to stop working as a cook and ended up spreading the disease further. She eventually returned to quarantine (and spent decades there on an isolated island). It appears to me this is a case that pretty clearly falls under the governmental function of protecting individual rights (not to be infected by others).
This pandemic needs to be tackled as a societal response instead of an individualistic response. With a science-driven, probabilistic approach and using statistics instead of basing ourselves on pre-existing positions and convictions based on whatever politics we might belong to.
Public Service Announcement (Part II)
You will find below some suggestions for behaviors that might help identify different susceptibility risks and factors this summer as things re-open. These guidelines are not perfect, and, to quote Harvard Business School, “it depends” on your circumstances which of them are more relevant to you. The corollary to that, is that the trick is to know what it depends on. The important part is to understand that this is not a set of binary recommendations. Risk is on a sliding scale and different factors have different importance depending on your personal situation.
You are probably familiar with the known individual risk factors: age and pre-existing conditions are still the single largest contributors, as far as we know. I personally believe a medical history of inflammatory disorders (asthma, etc) also increases risk, but it is hard to quantify that or to find hard data on that. It stands to reason, though, since the single largest driver of fatalities appear to be driven by a hyperactive response of the immune system to the virus.
It is also very, very important to consider the sheer volume of virus (size of the viral “inoculum”) you are potentially exposing yourself to with your behavior: time spent in enclosed spaces, with a lot of people for long-term interactions, are very, very risky, obviously, especially if containing younger individuals who might have had promiscuous contacts with a large number of people beforehand, and might well be asymptomatic.
However, even open spaces are risky if in close physical contacts (handshakes, hugs, etc) with multiple parties. For example, we are learning from parts of developing world, like India and Brazil, that even belonging to a younger demographic does not protect individuals from severe prognosis and possibly fatality: so population density / inoculum size could outweigh young age / lack of pre-existing conditions.
Even the amount of physical distancing is relative. Say the person running / biking across from you happens to be a super-spreader, breathing heavily, with a tailwind at his back and close to you? It is impossible to calculate the risk. It is probably not 100%, but it is not 0% either. If you are young, vigorous, with an impeccable immune system (Are you? Really? How do you know?), and avoid touching your face and wash your hands when you are back at home after the run, your immune system is likely to beat this since you are probably not going to be exposed to too many copies of the virus. But you still could become an asymptomatic spreader and nobody would be able to check that.
So, it’s great to walk outside and exercise, but unless you live in a desert with nobody around for miles, always carry a mask (and wear it in case you come across other individuals / groups), stay as far apart from other people as possible, avoid physical interactions unless you have isolated with these individuals for weeks, and don’t talk loudly on the phone without a mask while walking (or, ideally, ever).
This pains me personally as a Southern Italian, but again there are some lessons here from the Japanese: no touching, no hugging / kissing on the cheeks, no handshakes, no buffets, we should think of individually-wrapping snacks and cookies. All those behaviors limit infectious disease spreading. Civilizations in the Middle East and elsewhere have developed religious precepts prohibiting the consumptions of certain foods, mainly to avoid diseases.
The whole world is going through this tragedy like us: we should all learn from other experiences. The only thing that might move faster than this virus is information. And we all have a lot of things to learn.
Follow Otello Stampacchia on Twitter: @OtelloVC
This article expresses the personal views and perspectives of the author. The views and perspectives expressed here do not necessarily represent the views or perspectives of Omega Fund Management, LLC or any officer, director, partner, member, manager or employee of Omega Fund Management, LLC or any of its affiliated entities.