As with many things in life, grappling with a pandemic well is hard, but the consequences of not doing it well are worse.
First let’s quickly recap some of the best. As I write this, New Zealand and Australia are ending their lockdowns after only a few weeks (about a month, more or less). They have nearly eliminated the virus, so they can go back to nearly normal. The exceptions are that they must strive to block re-infection from abroad, and they must be vigilant about noticing and stamping out any infections that appear.
Germany is an example of the next best situation. They have knocked the prevalence of the virus down to low enough levels to begin cautiously reopening society. However, because they have not eliminated the virus, everyone must still take precautions to impede its spread and flare-ups must be squelched rapidly.
Countries that have not done so well are now in a painful position. Reopening is not safe until the level of contagion has come down to a point comparable to Germany’s. After the virus is allowed to get a head start, wrangling it down to such a level requires longer lockdowns, perhaps longer than governments (and people) are willing to tolerate. More people get COVID-19. Some patients die. Some survive with long recovery periods. There are now multiple reports indicating some survivors may incur damage in a long list of organs including but not limited to lungs, heart, liver, kidneys, intestines and brain. Thrombosis (abnormal blood clotting) occurs in an alarmingly high proportion of patients across a wide span of ages, so tissues can get a double whammy of oxygen deprivation as COVID pneumonia sets in and as clots block blood flow. When a clot is in the brain, it causes a stroke.
The virus does not merely take patients out of the workforce for a couple of weeks while they are ill. It can kill, and it can leave some people permanently impaired. We don’t yet understand how many. (For a couple of good overviews of what we do and do not know so far, see WebMD and New York Intelligencer.)
If governments and organizations are thinking about how lasting impairments change the stakes, they are not talking about it much (if at all) where the public could hear. We have to puzzle out for ourselves what makes sense as a lockdown exit strategy for each country.
So let’s get to it. My countries are the USA where I began, and the UK where I live now. I’ll use them to frame my thinking.
United Kingdom (Why Lockdown Exit Via Immunity Passports Makes Little Sense)
The UK eventually got around to locking down, although it is looser than in some other countries such as Spain. Being in lockdown positions the UK for a potentially earlier and safer emergence than the USA, so I will begin here.
Lockdown was delayed by a government decision to let the virus rip through the population to emerge with herd immunity when about 80% of the people got infected. Singapore shows what could have happened. Instead, the let-it-rip delay allowed the virus to spread. At last, calculations by Imperial College London somehow drew the government’s attention to the large number of deaths that would occur, not to mention overwhelming the National Health Service. That report’s projections were milder than other epidemiological models, but it did the job of jolting the government into belated action.
Mathematical models are useful for broad brush planning, but to reopen society safely, we need to know whether weeks of having most people stay mostly at home brought the prevalence of the virus down enough to be at least near the German level.
Official counts of confirmed cases and confirmed COVID-19 deaths are not especially informative. As in most countries, testing is not done widely enough to make those numbers meaningful. To add to the confusion, British death counts for the pandemic are generally limited to deaths in hospitals. Deaths in care homes (a hotbed for the pandemic) and at home are excluded.
Instead, let’s compare total death rates with typical death rates at the same time of year. The higher total death rates are now compared with the norm, the more prevalent SARS-CoV-2 infections must be. This is a reasonable comparison regardless of how a country has responded to the pandemic, although lockdowns do affect how much weight we should give it. For example, lockdowns have been reported to reduce the instance of seasonal influenza substantially (e.g. 44% in one study). That implies deaths from flu should be lower than usual where a country is in lockdown. If total deaths are higher than normal, COVID-19 is probably responsible for not only the additional deaths, but also some deaths that would normally occur from other infectious diseases. Some of that responsibility can be indirect where people did not seek lifesaving medical attention they needed, dying because fear kept them away from hospitals overwhelmed with COVID-19 patients.
Last week I noticed the UK’s total death rate was about twice as high as normal for this time of year. In the USA, only a little more than a third of the “excess” deaths were officially attributed to COVID-19. (See the Washington Post.) For both countries, that says COVID-19 is still widespread, or at least it was a couple of weeks earlier than the date on the death rate figures.
Reopening society has to take that into account. In New Zealand and Australia, as people go out again, they can assume little or no virus is circulating among the population. In Germany, they can assume not much is circulating and the government will promptly sequester infected people. In the UK, people must assume a noticeable portion of the people around them are contagious.
A few weeks ago the government began talking up immunity passports as a way to restart the economy. (The UK government is focused on enabling businesses to make money, pay wages and pay taxes again, and not so focused on other aspects of society.) People who have survived COVID-19 would get a special passport certifying them as immune and therefore able to resume activities without risk of getting COVID-19 again. They could go to work (make money and generate profit for employers), go shopping (spend money), and socialize without fear.
The World Health Organization currently advises against immunity passports. WHO pointed out, correctly, that nobody knows yet whether surviving COVID-19 leaves a person immune to getting it again. But there’s more to it than that. If surviving the disease does confer immunity, we don’t know for how long, or whether immunity is only against the variant (A, B or C) that made the person sick. We don’t know what level of antibodies a person needs to have for immunity and whether asymptomatic or mild cases produce enough antibodies. We don’t even know for certain whether the virus can lurk in a survivor’s body after recovery, which some viruses such as herpes do (allowing them to spread long after recovery).
Let’s be generous and assume the answers to those questions will turn out perfectly for immunity passports. Would that allow enough workers to mobilize to restart the economy?
How much of the population might be eligible for immunity passports?
Let’s be doubly generous and assume everyone who has been infected emerges with enough antibodies to be immune, even if they were asymptomatic.
Not many studies have emerged yet that can claim to show how much of a general population has been infected, although Iceland in particular is striving to do enough testing to tell us that. Testing of maternity patients from late March to early April in New York found 13.7% tested positive, of which 87.9% were asymptomatic when tested. (For details, see New England Journal of Medicine.) At the time, the hospital that did this study was near “the epicenter of the global epicenter” so the UK’s prevalence should be lower.
Let’s be even more generous. We’ll estimate 13.7% of the UK population has been infected, are immune to re-infection for a substantial length of time, and are no longer shedding virus. We’ll also make the dubious assumption that the 13.7% are evenly spread across age ranges, even though we know the elderly in care homes are especially badly hit.
Relying on immunity passports would not put 13.7% of the workforce back on the job because some of them emerged with lasting impairments. We don’t know how many, and we don’t know what proportion of them are so impaired that they can’t do their former jobs any more.
Let’s be generous again and merely round it down to 13%. Immunity passports would unleash 13% of the workforce… assuming all our generousity is warranted.
That lands with a dull thud instead of celebratory fireworks, doesn’t it?
United Kingdom (Exit Planning Continued)
So immunity passports are not the holy grail of exit planning. We might get a tenth or so of our economy running again. That isn’t much. What else could we do?
It turns out that while the USA has mostly been a pandemic madhouse, some Americans have come up with ways to keep businesses running.
The Braskem petrochemical factory at Marcus Hook, Pennsylvania, makes raw material that is needed to manufacture personal protective equipment (PPE) such as face masks and surgical gowns. Nobody made the factory stay open. But 43 of its workers volunteered to move into the factory, living there away from everyone else and working 12 hour shifts 7 days a week for 28 days to feed the PPE supply chain. They called it a live-in. They were paid handsomely. Visitors and breaking the group’s isolation weren’t allowed, even causing one worker to miss the birth of his first grandchild. The closest they got to their families was a police-escorted “drive-by visit” at the midway mark by households waving signs and cheering from their cars at too much of a distance to talk. The crew made 40 million pounds of polypropylene, enough for half a billion N95 masks. (Covered by Washington Post.)
Notice that this only worked because all of the volunteers were healthy at the start and they all committed to absolute, stringent isolation of the crew from everyone else.
This illustrates a concept I’ve discussed with family, friends and business partners. Such a concrete example makes it easier to grasp than abstract discussion.
There are far more people who haven’t contracted the virus than people who have survived it. Successfully exiting lockdown without a vaccine or reliable treatment requires finding ways for the unexposed to work and interact with each other but not with anyone who could expose them.
This is exceedingly tricky to implement. It begins with categorizing people in terms of COVID exposure:
- Isolated stringently enough for long enough to be assured of being unexposed (the unexposed cohort)
- Unable to isolate stringently, but maintaining physical distancing and hygiene as much as possible, including face masks when outside the home, to keep risk of exposure low (the at-risk cohort)
- Previously infected and known to be immune (the immune cohort, which depends upon evidence we don’t have yet and reliable antibody tests we don’t have yet)
- Not reliably maintaining, perhaps even deliberately violating, physical distancing and hygiene measures (the tinderbox cohort, wide open to infection)
- Moving or possibly moving between one category and another (the transitional cohort)
If we think of reopening in terms of what each of these cohorts can do and what it needs, we can reach solutions that are reasonably safe and productive for much more of the population than if we rely on immunity passports. Actually doing it requires radical changes in the way some workplaces operate, the way workers are matched up with job roles, and most importantly immense societal compromises. The very idea of dividing people into such classes is abhorrent in liberal democracies.
Despite that, let’s look at it anyway to get a sense of what we could be facing. Until we have either an effective vaccine or a reliable treatment, opening up in other ways such as by type of facility (school, small shop, factory) is likely to spark fresh waves of infection. Opening up by organizing cohorts to minimize the chance of spreading the virus is an alternative. Personally, I prefer extra bother over extra illness and death.
Factoring In the United States
This can be useful in the UK. It is practically essential for the USA, which is rapidly becoming a reservoir for SARS-CoV-2 due to, among other things, throwing its pandemic response playbook out the window. We are approaching a point where the rest of the world will need to treat the USA like Typhoid Mary, allowing Americans to visit only after passing through rigid quarantine. Without something akin to leveraging cohorts, organizations in the USA will have to operate on the premise that everyone could be contagious and everyone needs to be protected against contagion. For many businesses that stance would be extremely difficult.
The Braskem example may be the best meat processing facilities can rely upon. It would require radical changes to the way they work. In those facilities, people cannot maintain distance and hygiene. Wearing masks and daily disinfection of the facility have not been enough to prevent outbreaks. When the virus infects someone in a meat processing plant, it can quickly sweep through the facility, then through the workers’ families and the community where the workers live. Tyson Foods, a giant in the USA meat industry, warns that the American food supply chain is breaking under the strain.
For meat processing workers, going to work would become even more brutal than it already is. An entire crew would need to self-isolate as much as possible with their families for two to three weeks before going in for a few weeks of solid working and living on-site, like the Braskem team. Then either the facility would need to shut until the next crew is available, or it would need to rotate another crew in.
This should be to keep the supply line for meat operating at some level, not use this crisis to squeeze people for higher productivity. Meat processing workers are typically not paid well and their jobs are too punishing to pile on heavier workloads. Braskem did not expect its people to “go the extra mile” for standard pay and the company did what it could to make the experience bearable. The meat industry would have to do the same. Those costs would show up in the price of meat at grocery stores, but meat would continue to be available to buy and farmers would continue to be able to sell the stock they raise.
The impact need not be this radical on all businesses. For example, an inlaw of mine works for a small company that makes fleece garments. The production facility is already set up so that workers don’t have to all be there at the same time to work their shifts. The materials and machines are ready all the time. Workers can go in to do their work at whatever time suits them, or can be readily scheduled so people will not have to use adjacent workstations. At-risk and immune cohorts can both work there with little change to procedures. Unexposed people would transition to at-risk by working there because they would no longer be fully isolated, although their risk of infection at work would be low.
Some niche garment-making businesses go farther, with workers sewing at home to company-provided patterns and standards. Anyone who is not sick can do this, although the company may require that workers are not in the tinderbox cohort in order to reduce the risk of shipping virus-laden stock.
In the UK, government does not seem to understand business well enough to set rules that can function across the board. This is probably true elsewhere. It doesn’t necessarily mean government officials are incompetent. They aren’t experts in how various businesses operate because they aren’t running such businesses themselves. When they have an idea that wouldn’t fly in real life, they need to be educated by people with genuine experience and expertise.
For instance, the government talks about reopening restaurants with perhaps half the tables not available for use in order to maintain social distancing. If you have operated a restaurant, you know margins often cannot tolerate wiping out half the customer seating. Some restaurants considered the dilemma of how to protect customers and, where their space allows it, are setting up barriers of some kind to shield booths or tables from other nearby booths or tables. Done right, this can be safer and perhaps allow them to seat more customers than if they simply take half the tables out of service.
Businesses will need to set new rules for themselves, preferably with a little guidance from experts in the way infections spread. A great many businesses will have complex decisions to make, but some (especially those that produce goods or services) could devise effective solutions to their dilemmas by thinking in terms of the cohorts among their staff. The immune cohort might handle all interactions with the public (with the public regarded as simultaneously needing protection and being contagious). The unexposed cohort might all work together, separated from other cohorts. The at-risk cohort might work together with special attention to spacing and other measures to prevent contagious spread if one of them becomes infected.
Within the cohorts there can be subsets. As an example, I would be in the at-risk cohort. My spouse is a medical secretary at a hospital, so I cannot isolate enough to be in the unexposed cohort. There is always a small chance the virus might hitch a ride home and it might sneak past the decontamination procedure upon arrival. However, my risk of a severe case if I catch the virus is somewhat elevated. If I work in an at-risk cohort, I may need an arrangement slightly different from the others to protect us from each other’s small potential of exposure (working in a separate room, wearing a better mask, or some such).
This leads to yet another hurdle which only gets noticed if we think our way through this. No worries, that next hurdle has a solution, uncovered by thinking it through. Certain businesses are already looking to take care of it. Confidentiality agreements wouldn’t let me walk you through that one too. But the solution shows up from focusing on what we need to accomplish and what we have available to work with, not on how to get back to what is familiar. Standard practice for some of us, and maybe about to become standard practice for more of us.
Many thanks for reading through these posts. I hope these ramblings are of some use to you.
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