The Big Picture: Stages in our Pandemic “War”

For brief descriptions of and links to recent posts, click here. For an inverse-chronological list with links to all posts after January 23, 2017, click here. For a subject-matter index to posts before that date, click here.

Stage One—Testing, Tracing Contacts, and Isolating the Infected: the Lost Battle
Stage Two—Locking Down and “Flattening the Curve”: now in process
Stage Three—Finding the recovered who are immune non-carriers and putting them to work
Stage Four—A medicine: the “Wild Card”
Stage Five—a Safe and Effective Vaccine
Conclusion

There are two things that no leader in wartime ought to do. The first is to try to fight the last war, using an obsolete strategy. The second is to refight a lost battle.

The French made the first error in World War II. They created the “Maginot Line,” a series of fixed fortifications, which the Germans with their Panzer (tank) divisions easily circumvented. As a result, most of France fell and remained Nazi-controlled territory for most of the war.

The Brits avoided the second error after their horrendous early defeat on the European continent. Instead of fighting to the last man, they beat a strategic retreat from Dunkirk and saved the bulk of their fighting force. Then they devoted their energy and ingenuity to the so-called “Battle of Britain”—the air war over France, Germany, England and the English Channel. Their pyrrhic victory in that battle probably saved Western civilization from Nazi brutality.

We have not yet made France’s error in the war against Covid-19 because the scientists have been in charge. While they have noticed important similarities among the Covid-19 virus and the viruses that cause SARS, MERS, influenza, and even the common cold, they have been just as attentive to important differences. As good scientists, they care about detail and have assumed nothing. From the very beginning, they have been fighting this war, not the last one.

Unfortunately, our species has not been nearly as wise and prescient as the Brits after Dunkirk in letting a lost battle go. Only South Korea, Taiwan and Singapore appear to have won the battle of testing, tracing contacts and isolating the infected. The rest of the world, including the United States, has self-evidently lost that battle already, by weeks if not months.

So if we want to win this pandemic war as a species, in places not so wise and/or lucky, we’re going to have to consider the likely ebb and flow of the entire war, in all its various stages. We’re going to have to plan in advance and respond flexibly to reverses and unforeseeable events. To that end, we should consider the five stages through which this war will very likely pass:

Stage One—Testing, Tracing Contacts, and Isolating: the Lost Battle. Outside of South Korea, Taiwan and Singapore, this battle already has been lost. Once you have known cases in the tens or hundreds of thousands, you have to admit that unknown cases must bulk at least the same order of magnitude, and perhaps an order of magnitude larger. Then there is no hope of even testing everyone likely infected, let alone tracing all their contacts retroactively over a period of several weeks or months, especially when your testing “infrastructure” has badly lagged. If nothing else, the United States’ complete lack of discipline and consistency in simply testing arrivals from China during the height of its epidemic demonstrates the utter futility of relying on this approach now.

This doesn’t mean that testing, tracing contacts and isolating the infected no longer has relevance as a tactic. It can work in special instances like the infamous funeral in Albany, Georgia, or in isolated, local hot spots.

But it’s not going to save already established citywide hot spots like New York or New Orleans from a full-blown explosion of cases. For nations and regions that have already missed the boat, testing, tracing contacts and isolating the infected is no longer a viable strategy. The only thing that can minimize the suffering and death in these places is adroitly moving on to the next stage.

Stage Two—Locking Down and “Flattening the Curve”: now in process. The purpose of and prognosis for this stage is now well known. The idea is to slow the exponential growth of new infections so as not to overwhelm hospitals and health-care providers, and to stay locked down until the exponential rise of new infections goes flat and even begins to decline. It’s the only viable strategy yet devised for cities, states, regions and nations that have already missed the boat of Stage One.

This is entirely a defensive stage. All it can do is slow the pandemic’s explosive growth unless or until we have a vaccine. Its logic requires (apart from overlap with Stage Three) that we maintain the lockdown indefinitely, lest “virgin” people mix with infected and recovering ones and so restart the cycle of exponential growth of new infections all over again. (No doubt this dismal error will recur, perhaps repeatedly, in places where leaders and their people fail to understand the terrible logic of this stage.)

Stage Three—Finding the recovered who are immune non-carriers and putting them to work. Outside of lucky and prepared places like South Korea, Taiwan and Singapore, this stage is the first part of the “war” that we can properly characterize as offensive, rather than merely defensive. If we can identify people who’ve had the disease and have recovered, and who are both immune and no longer carriers, we will have an ever-growing army of invincible pandemic fighters. They, and only they, can begin to get back to “normal.”

Not only can they go anywhere and do anything, without risk to themselves or others, as if the pandemic had never occurred. In particular, they can: (1) supplement and protect the first-line defenders, i.e., doctors, nurses and hospitals; (2) test suspected new cases without risk; (3) bring food and other necessities to the isolated but fearful uninfected; (4) perform essential work like keeping food growing and flowing, transporting the sick, maintaining critical supply chains, and keeping the lights and power on; and (5) jump-start and expand the customer bases of closed and barely operating small businesses, such as restaurants, bars and even entertainment centers. In essence, these recovered, identified and “cleared” people can begin, slowly but steadily, to revive the general economy.

The key to all this, as I explained three weeks ago, is blood tests for antibodies, as distinguished from nasal-swab tests for active virus. There is now evidence that patients recovering from Covid-19 develop two kinds of antibodies: a temporary one from about six to 20 days after infection, and later a more permanent kind.

We still have lots of good science to do to determine how much of which kind of antibodies in the blood confers immunity and rules out further contagion. But prior experience with other viral illnesses, including vaccines, suggests that such tests are possible.

Once we’ve done the right science well, we can test not only people who’ve previously tested positive for viral load, but also the higher number of suspected but never confirmed infections. As and if people’s antibody tests “clear” them, they can go to work and back to normal life, as if vaccinated, even long before an effective vaccine arrives. It goes without saying that this testing should be entirely gratis to the subjects, financed by government as a public necessity.

These “cleared” people would not necessarily return to their old jobs. With their confirmed immunity and freedom from contagion, they could do other work of much greater social benefit. Especially in the early phases of Stage 3, they will be a precious resource whose immunity and labor must not be wasted or misused.

Their most important early use would be giving beleaguered medical first responders some relief. There is growing evidence that “viral load,” in addition to a patient’s personal immune-system characteristics, fixes the severity of the Covid-19 illness, as well as its mortality. As this evidence becomes confirmed, it will make no sense to stress our non-immune doctors and nurses with impossible 60-hour weeks in which they regularly encounter very sick patients coughing, sneezing and breathing all over them.

Chronic stress and fatigue only impair people’s normal immune function. To subject our doctors and nurses to them and to great viral loads simultaneously is to treat our elite shock troops as cannon fodder. It would make much more sense to give them a respite of a day or two after encountering a formidable viral load, both to increase their own chances of survival and to assess whether they are falling ill and therefore an increased danger to patients.

Dr. Siddhartha Mukherjee has explained the theory in a brilliantly written must-read New Yorker article. He speculated whether we might measure viral load with something like the radiation dosimeters that workers in nuclear power plants wear. That seems unlikely: just measuring the virus’ presence in individuals is already hard enough, as well as slow and expensive. But with current hospital computer systems, it would be easy enough to keep careful records, for each caregiver, of things like being sneezed and coughed on by a very sick patient, or installing a ventilator in one (which requires very close contact). Then caregivers’ workloads and respite periods could be arranged accordingly.

Two points about Stage Three bear emphasizing. First, the lockdown for “virgin” people (those neither infected nor recovered) must continue as long as Stage Three lasts, or at least long enough to reliably establish “herd” immunity among the general population. So the lockdown should last at least months, not weeks. It might even last until a reliable vaccine is generally available.

Second, although Stage Three begins the transition period back to normal life, it will not release everyone from lockdown at the same time. It will only release those who have caught Covid-19, have recovered, are no longer carriers, are immune, and have been so tested and therefore “cleared.” So Stage Three will mark the beginning of the end, but nowhere near the final end chronologically.

Stage Four—A medicine: the “Wild Card.” No one can now predict when or whether a medicine for Covid-19 will ever exist or, if so, what it will do. As compared to vaccine development, research on medicines is random, haphazard and wholly unpredictable. It depends, in large measure, on rare and extraordinary scientific insight, serendipity, and plain dumb luck.

In contrast, the process of developing a vaccine is well known and straightforward, at least in theory. It has worked for many viral diseases, from smallpox and polio to (until recently) measles and mumps. What takes so long is maximizing a vaccine’s protection and confirming both its safety and effectiveness in lengthy, large-scale human trials.

At present, the most promising approach to a medicine is the use or synthesis of antibodies that real patients have developed in recovering from the disease. Scientists in China have had some preliminary success with this approach, and it seems promising enough to merit serious, expedited research.

But there are hurdles in using antibodies from real patients’ bodies in other patients. They include unforeseen immune reactions and obvious problems in scaling up. (Individual patients’ bodies do not make robust medicine factories.) There are also obvious problems in synthesizing “purer” versions of the same antibodies at scale and with sufficient purity to avoid unintended reactions.

Nevertheless, this approach has had limited success with other diseases. So far, it seems the most systematic approach and the one most likely to achieve limited success in the short term.

But neither this approach, nor any other now known, seems to offer anything like a “cure.” A pill or injection that will cure every case of Covid-19—let alone an advanced case with pneumonia, lung damage and organ failure—is highly unlikely. The best we can reasonably hope for is a medicine that: (1) reduces the incidence of infection among exposed people, or for a limited class of them (such as those who do not react negatively to a specific antibody); (2) relieves symptoms if given soon enough after infection; (3) makes serious complications less likely if administered early enough; or (4) in limited, highly specific cases can bring patients back, albeit greatly impaired, from the brink of death.

There is absolutely no way of knowing, in advance and without extensive clinical experience and double-blind human trials, whether any particular natural or synthesized antibody or medicine will have any one of more of these effects. That’s why the very notion of a “medicine” must remain a “wild card” in planning the war against Covid-19. No one can predict when one will be found or what it can do. All we can do is exploit one, if discovered, to the best of our ability. As a result, the discovery and development of a medicine are far too uncertain to serve as reliable strategic factors; they can serve only as tactics.

Stage Five—a Safe and Effective Vaccine. As these brief descriptions of the earlier stages suggest, the pandemic will not be “over,” in any real sense, until we have developed a safe and effective vaccine. Even then, it may take many months to ramp up production of the vaccine worldwide and bring all the uninfected “virgins” out from hiding and vaccinate them.

No less an authority than Dr. Anthony Fauci has guesstimated the time required just for vaccine development and testing as a year to eighteen months. If you don’t consider the job done until the vaccine has reached all the far flung corners of the Earth and relegated Covid-19 to the same rarity as polio or smallpox, winning the “war” may take even longer than that.

During all that time, recovered patients “cleared” in Stage 3 will steadily continue to increase in number. After all, the vast majority—well over 90%—of infected patients will recover. Most, if not all, of them eventually will be “cleared” by antibody tests to return to normal life. But all this will take time—months and months, not weeks.

As Stage Three progresses, Covid-19 “virgins” in the high-risk categories will have a terrible choice to make. To protect themselves, they will have to stay in lockdown and continue to practice social distancing for all this time. Or they will have to bite the bullet and risk being among the last to die in a nearly-extinguished pandemic. Isn’t that just as depressing as being the last soldier to die in a waning war?

The dilemma that these uninfected “virgins” pose, both to themselves and to the larger society, will require vast moral and economic changes in the larger society as it recovers economically and gets back to normal life. Handling them will say much about how our society evolves, if at all, from its present cruel and short-sighted reliance on social Darwinism to one based on compassion, caring and concern for all.

Conclusion. Our pandemic “war” will not be won until we have a safe and effective vaccine and have used it to give our entire species effective herd immunity. While prediction is hard at this early stage, the most conservative estimate of a time frame for that “victory” is two years. During all that time, there will be innocent, high-risk “virgin” people whose lives, health and safety will depend on at least partial lockdown and social distancing. No doubt there will be places and leaders that “jump the gun” and sacrifice these innocents to the harsh god of a quicker economic revival.

How this tension between compassion and “get on with it” fever plays out will vary widely from place to place, just as the reluctance to lock down in the first place has condemned some rather remote places to becoming minor hotspots. In making this crucial choice, places and leaders will reveal, for some time to come, who and what they really are.

The most crucial choice of all will be how we handle “cleared” Covid-19 survivors in Stage Three. We can take a “laissez faire” approach and let them decide, under the aegis of “personal freedom,” what they do, when and where they do it, and whether they make any contribution to the common “war” effort at all. Or we can organize and put them to work fighting the pandemic. We can, for example, let smart people with medical and scientific expertise return to managing venture capital and speculating in the stock markets; or we can put them to work designing better ways to organize our fight against the pandemic.

The “laissez faire” approach is not the one we took in World War II. Then we drafted all able-bodied men and accepted all female volunteers and put them to work in the war effort. With intelligence tests and careful biographies, we evaluated every draftee and volunteer individually and put him or her to the highest and best use in fighting the enemy. Anyone at all familiar with the war effort knows that, from rationing gasoline, food and automobile tires to running the Manhattan Project in strict secrecy and putting women to work as “Rosie the Riveter”, our entire nation was involved in a carefully planned, beautifully organized, top-down crash project to win the war.

We will need something like that in Stage Three if we are to fight this pandemic effectively. It will, or course, go against the grain of libertarianism that has so saturated our national culture and ideology. But it will shorten the war, save tens of thousands of lives, and perhaps give our people coherence and a common goal. Who knows? It might even show them what’s been missing from our hedonistic, libertarian, selfish, “anything goes” culture for the past generation or two.

Our draftees’ and volunteers’ effort in World War II was unlimited in time. No one knew, in advance, when the war would end or even if we would win it. For many, their fight lasted the entire four-year duration of our nation’s part in the war.

In contrast, this commitment will be unlikely to exceed two years. The path toward vaccines against viral diseases is long and winding but well known and well traveled.

Whether those of us who survive and recover from Covid-19 can devote that much time to assuring a quick and efficient national recovery will tell us and the world a lot about about ourselves as a nation. Most of all, it will reveal whether we can ever recover our lost national greatness, and whether we can truly compete with China for leadership of our species.

Permalink to this post