By Kevin Roche
Periodically reviewing the big picture in regard to the coronavirus epidemic can be useful. Once it becomes apparent that there is a widespread infectious disease epidemic, there are two basic strategies that can be employed to address the outbreak. The assumption here is that eradication is not possible, in the short term or long-term. We live with coronaviruses every day and we are going to end up living with this one. So one strategy is to mimic eradication by suppressing transmission of the virus as much as possible. Since the primary route of transmission of the virus appears to be directly from one human to another, that means minimizing contacts between humans, especially between an infected person and uninfected ones. This strategy is the one that has been employed by most countries and most states in the US. The extreme stay-at-home and business shutdown orders are designed to severely reduce contacts between people and limit infections, with the goal of driving new cases to zero.
The other strategy is adaptation. This doesn’t mean doing nothing to try to limit the damage done by disease, but it is more of a mitigation or control of spread approach, with targeting of vulnerable populations for extra protection, and adoption of basic hygiene and other measures that might limit infections, but otherwise allowing the population to go about its business as usual. While it might not be expressly framed this way, the adaptation approach is aimed at achieving population immunity. As we never tire of explaining, in the absence of eradication, the only way to control coronavirus disease is by population immunity. That either comes from exposure and development of antibodies or a vaccine that prompts antibodies. I am more dubious than many about a vaccine that is universally effective and has basically no side effects being available in the time frames people optimistically put out there.
The consequences of the two strategies are very different. Let us look at the second one first. You will likely see a higher number of cases, serious illness and death earlier in the epidemic’s course, because you aren’t trying to totally suppress it. The infection spreads more rapidly through the population, and you begin to relatively early on have a significant number of people who have been infected and recovered. As this pool of recovered people grows, the virus transmission begins to slow–there are just fewer targets. Eventually you reach a point at which transmission levels are very low and the epidemic has ceased, although, as with influenza, you will continue to have some background level of infections. From an economic perspective, with a serious epidemic there would likely be some impact even with a mitigation strategy. People will self-isolate, affecting consumer spending, there may be more medical costs and there will be loss of productivity from absenteeism due to illness. But that effect will be fairly small. In the 1957 flu epidemic, when a new strain arose, on a population of 172,000,000, there were 116,000 deaths estimated in the US. Even though this epidemic affected children heavily, nothing was shut down. The economic effect was minor. The adaptation strategy does not rely on a vaccine and fairly quickly gets you to a point where the epidemic is over.
The suppression strategy has a far different impact, both economically and from a public health perspective. By design it has an enormous impact on jobs and revenue for business. If you shut businesses down and tell people to stay home, the consequences are obvious (except to Governors apparently) and we have seen them. In addition, that job loss, and the fear engendered by actions suggesting such a high level of danger, keep people from seeking needed health care, cause mental illness, cause drug and alcohol abuse, cause child and spousal abuse, lead to homelessness and food insecurity and cause other damage. The damage tends to be more severe at lower income levels. But the other consequence of the suppression strategy is that it can never end. Since you aren’t eradicating the virus, if you let up on your extreme suppression efforts, infections will rise. So if you think that was the right strategy you can’t stop it unless and until you have a widely effective vaccine, otherwise you should have taken the adaptation approach to begin with. You are condemning people to a vastly lower quality of life and extended anxiety for an indefinite period. And, as we have seen in Minnesota and elsewhere, this extreme suppression strategy rarely completes succeeds at stopping infections and deaths.
The approach taken would obviously depend on your perception of the threat as well. By now, we know that this virus is not a significant threat to the vast majority of the population, especially younger people. And we know it is a real threat to the frail elderly. So the strategy would appear obvious. Avoid economic and non-economic harm by allowing continuation of normal life while sequestering and protecting the vulnerable. So why aren’t we doing that?