Flattening the Curve • The Case for Vertical as Opposed to Horizontal Social Distancing

Posted In: News, ,   From Issue 894   By: Robert E Martin

29th March, 2020     0

Compiled by Robert E. Martin

As of Tuesday, April 7th,  Michigan now has a total of 18,970 cases and 845 deaths, with 80% of those cases reported in the Metro Detroit area. However, Detroit Mayor Mike Duggan expressed optimism for the first time in days Tuesday when the number of new cases in the city fell for the second consecutive day

Within the span of 4-weeks the crux of our reactive response has been essentially to shut everything down.  Universities and schools shuttered, sports activities and public gatherings cancelled, constitutionally guaranteed rights of assembly and civil liberties suspended, the economy in turmoil, and business activity is nose-diving - unless you own stock in items individuals are hoarding like hand sanitizers, disinfectants, and toilet paper (ah yes - our economy is certainly on a roll!)

As with each of you, I have been sifting through articles and searching for opinions, research, and data that might illuminate whether there might be a better approach to minimizing the risks of coronavirus than the economic turmoil and psychological havoc that is being wrought by social distancing.

This article is a summary of articles, research, and thoughts I have read upon the topic that suggest there may be a far better and more effective approach to deal with this virus.

But first, let us examine the data on the virus itself.

The Numbers Game • Comparing Apples to Oranges

Many opinions attempt to offer comparisons between COVID-19 and the various other forms of flu out there; however, there is about a 1.9% fatality rate with COVID and one tenth of one percent for the flu, which means the fatality rate of COVID-19 is actually 19X higher than the flu!

Moreover, flu season is 6-8 months long verses what COVID has done here in barely over 2 months. By most research COVID has a transmission rate 2.5 - 4X that of the flu. Some new studies coming out are beginning to indicate it could be even more contagious than that.   More important, 5%-10%of infections need hospitalization, whereas that number is about 1% with the flu. 

The numbers move very fast, and will keep moving faster as this progresses towards the "peak". Two days ago we crossed the threshold of 1,000 dying per day (and still growing).  We have had some success with the lockdown reducing growth from doubling every 3 days, to doubling every 5.  

However, a sobering reality is that we are less than a week away from this thing killing over 2,000 dead per day which will make it the #1 killer in America (per day) beating heart disease and cancer.

But guess what? At that point the disease has barely started. We still won't even have 1M infected.  Less than 1/3 of 1 percent of our country's population will have it making it the biggest killer in our country.  Extrapolate that 5 day doubling time for just 1 month and see what happens, much less bringing it up to 20% of the population like a flu season.

Therefore, dealing with these sobering realities, we need to stop comparing apples to oranges - and remember - this thing spreads 4x as fast as the flu because we are dealing with exponential mathematics. 

More disturbing is that there are reports of deaths involving 35-year-olds in good health; in fact one, a baseball coach and lifelong athlete - no known health conditions- dead.  Certainly those in younger subsets are in lower risk demographics, but like all the others, it randomly takes people of good health and no underlying or past health issues. 

We already know COVID-19 has a much higher rate of degrading to a severe pneumonia very quickly if you have any underlying health concerns, especially: Heart issues, Diabetes, Obesity, If you smoke, If you are over 60, even more if you are over 70

Can you imagine how this impacts our society with the obesity and type 2 epidemic?  The baby boomers aging - a large chunk of not just our population, but also doctors when we are short on them already (see age demographic). This virus could truly damage our society by many orders of magnitude greater than the flu. 

Looking at the doubling rate today, it now appears like the doubling rate is 6 days.  Yesterday it was 5 days doubling. A couple days before that it was 2-3 for the past month before that.  We are beginning to see the effects of the various lockdowns, and that we are catching up to the curve in testing - both good things.

It's difficult because it takes time to see the effects of lockdown or any change in societal patterns to reduce transmission rate.  COVID19 on average has a 6 day incubation period. Then for the great majority of people the next 5-7 days of mild symptoms. Then people degrade severely and very quickly.  There is a big lag in the numbers, so it takes a couple weeks to find out where the numbers are at today with incubation, mild symptoms, and lab confirmation of testing (new faster testing is coming). 

That is the problem with the exponential math of this spread and the delay before symptoms, even further delay before degradation to severe, critical or death. By the time you realize it's a problem - it's too late.  

If we would have waited for 10,000 deaths before locking down for example - with that two week lag time and 3 day doubling we were at - we would be at 160,000 deaths two weeks later before even beginning to see the "reduction in rate" that we are experiencing with our numbers now.  

What if we waited until 50,000 deaths (which would happen, and still might happen this month, since not all states mandated a lockdown?  We would be at 1.6 million deaths 15 days later when we just begin to see that reduction in rate. 

Flu incubation period: 1-3 days. COVID19: 4-14 days. 
Flu fatality rate:  .1%  COVID19: 1-5%+ (if you overwhelm the health care system, the death rate shoots up dramatically).  So 10X to 50X greater than the flu.
Flu hospitalization rate: 1%. COVID19: 5-10%.   So 5X to 10X greater than the flu
Flu transmission rate R.0 = 1.2.  COVID19: 2.5-4+

It's that final transmission rate exponential math that really makes those previous facts scary.  Taking it on the low side (2.5) comparison is comparing the difference between a 20% APR (flu) to a 250% APR (COVID19) or maybe even more than 400% on the higher side.

It is important to also note the data changes regularly, and there are reports that these numbers are both high and low -the most interesting thing to note, even on the very low side estimates, is that COVID-19 is staggeringly worse than the flu.  

At this juncture these things need to happen:

1. Roll out infrastructure so we can "afford" for this to hit a bigger chunk of society without skyrocketing death rates from overwhelming hospitals. Main things is hospital beds, ventilators, PPE, and medicine.  Things are starting to look much better in this category with the participation rates of big companies helping. 

2. Develop, find, test more antivirals.  This is also looking very promising -  we are finding some easily reproduceable medicines they are finding to be very effective.  Also, you do not need to rely upon Big Pharma.  Studies have shown that immunity is bolstered and recovery expedited in patients with high levels of Zinc, which everybody should get a daily dose of.

3.Develop a vaccine - this takes minimum 18 months even on a fast track including manufacturing and delivery times.  So we either keep society reduced for long enough for #3, or until we can coincide a roll out of 1 and 2.  

Regarding the lockdown. There is the hammer and the dance. The hammer is now. We must hammer the transmission rate below R1.0 to gain control.  Then reopen society with some restrictions.  This is the "dance". This buys us time for all 3 above options for us to mitigate the death toll from this.

The Case for Vertical Social Distancing

Without doubt, the most reasoned, rational, and logically developed argument I’ve come across supporting the case for Vertical Social Distancing comes from Dr. David Katz, President of True Health Initiative and the founding director of the Yale-Griffin Prevention Research Center, who wrote an opinion piece published in The New York Times.

Katz begins by noting that as we battle the coronavirus pandemic, and heads of state declare that we are “at war” with this contagion, there are two different kinds of military action: the massive carnage & collateral damage rendered by dropping the equivalent of an atom bomb; or the precision of a ‘surgical strike’ methodically targeted to the sources of our particular peril that minimizes resources and unintended consequences alike.

“This can be open war, with all the fallout that portends,” writes Katz, “or it could be something more surgical. The United States and much of the world so far have gone in for the former. I write now with a sense of urgency to make sure we consider the surgical approach, while there is still time.”

Katz points out two important facts: Outbreaks tend to be isolated when pathogens move through water or food, and of greater scope when they travel by widespread vectors like fleas, mosquitoes or the air itself. Like the coronavirus pandemic, the infamous flu pandemic of 1918 was caused by viral particles transmitted by coughing and sneezing. Pandemics occur when an entire population is vulnerable — that is, not immune — to a given pathogen capable of efficiently spreading itself.

“Immunity occurs when our immune system has developed antibodies against a germ, either naturally or as a result of a vaccine, and is fully prepared should exposure recur. The immune system response is so robust that the invading germ is eradicated before symptomatic disease can develop.”

Immunity is an important factor, especially insofar as we have yet to develop a vaccine. He points out how ‘If a germ can’t secure its hold on your body, your body no longer serves as a vector to send it forward to the next potential host. This is true even if that next person is not yet immune. When enough of us represent such “dead ends” for viral transmission, spread through the population is blunted, and eventually terminated.’

This is called herd immunity.

Katz argument states that what we know so far about the coronavirus makes it a unique case for the potential application of a “herd immunity” approach, a strategy viewed as a desirable side effect in the Netherlands, and briefly considered in the United Kingdom.

The data from South Korea, where tracking the coronavirus has been by far the best to date, indicate that as much as 99 percent of active cases in the general population are “mild” and do not require specific medical treatment. The small percentage of cases that do require such services are highly concentrated among those age 60 and older, and further so the older people are. Other things being equal, those over age 70 appear at three times the mortality risk as those age 60 to 69, and those over age 80 at nearly twice the mortality risk of those age 70 to 79.

“These conclusions are corroborated by the data from Wuhan, China, which show a higher death rate, but an almost identical distribution,” he continues. “The higher death rate in China may be real, but is perhaps a result of less widespread testing. South Korea promptly, and uniquely, started testing the apparently healthy population at large, finding the mild and asymptomatic cases of Covid-19 other countries are overlooking. The experience of the Diamond Princess cruise ship, which houses a contained, older population, proves the point. The death rate among that insular and uniformly exposed population is roughly 1 percent.”

Dr. Deborah Birx,the White House coordinator for the virus response team, is quoted as saying that even if all the social distancing guidelines are followed perfectly, the death toll in the nation could reach 100,000 to 200,000. Moreover, the United States already has the highest number of reported infections in the world, with 160,000, and has yet to fully ramp up testing, meaning that many cases are going undetected.

However, the most important component of Katz’ argument is how the deaths have been mainly clustered among the elderly, those with significant chronic illnesses such as diabetes and heart disease, and those in both groups.

“This is not true of infectious scourges such as influenza,” he continues.  “The flu hits the elderly and chronically ill hard, too, but it also kills children. Trying to create herd immunity among those most likely to recover from infection while also isolating the young and the old is daunting, to say the least. How does one allow exposure and immunity to develop in parents, without exposing their young children?”

The clustering of complications and death from Covid-19 among the elderly and chronically ill, but not children (there have been only very rare deaths in children), suggests that we could achieve the crucial goals of social distancing — saving lives and not overwhelming our medical system — by preferentially protecting the medically frail and those over age 60, and in particular those over 70 and 80, from exposure.”

Why does this matter?  Because the devastation wrought by this current ‘horizontal’ all-out approach to social distancing will be calamitous and possibly graver than the direct toll upon lives of the virus itself.

“The stock market will bounce back in time, but many businesses never will,” he concludes.  “The unemployment, impoverishment and despair likely to result will be public health scourges of the first order.”

“Worse, I fear our efforts will do little to contain the virus, because we have a resource-constrained, fragmented, perennially underfunded public health system. Distributing such limited resources so widely, so shallowly and so haphazardly is a formula for failure. How certain are you of the best ways to protect your most vulnerable loved ones? How readily can you get tested?”

With the current approach of ‘horizontal interdiction’,when containment policies are applied to the entire population without consideration of their risk for severe infection and then the work force is laid off en masse, young people of indeterminate infectious status are being sent home to huddle with their families nationwide.  And because we lack widespread testing, they may be carrying the virus and transmitting it to their 50-something parents, and 70- or 80-something grandparents. 

Concludes Katz: 

“If there are any clear guidelines for behavior within families — what I call “vertical interdiction”— I have not seen them. Such is the collateral damage of this diffuse form of warfare, aimed at “flattening” the epidemic curve generally rather than preferentially protecting the especially vulnerable. I believe we may be ineffectively fighting the contagion even as we are causing economic collapse.”

“There is another and much overlooked liability in this approach. If we succeed in slowing the spread of coronavirus from torrent to trickle, then when does the society-wide disruption end? There are many possible answers, but the most likely one is: We just don’t know.”

“We could wait until there’s an effective treatment; a vaccine or transmission rates fall to undetectable levels. But what if those are a year or more away? Then we suffer the full extent of societal disruption the virus might cause for all those months. The costs, not just in money, are staggering to contemplate.

“So what is the alternative? We could focus our resources on testing and protecting, in every way possible, all those people the data indicate are especially vulnerable to severe infection: the elderly, people with chronic diseases and the immunologically compromised. Those that test positive could be the first to receive the first approved antivirals. The majority, testing negative, could benefit from every resource we have to shield them from exposure.”

“To be sure, while mortality is highly concentrated in a select groups, it does not stop there. There are poignant, heart-rending tales of severe infection and death from Covid-19 in younger people for reasons we do not know. If we found over time that younger people were also especially vulnerable to the virus, we could expand the at-risk category and extend protections to them.”

“We have already identified many of the especially vulnerable. A detailed list of criteria could be generated by the Centers for Disease Control and Prevention, updated daily and circulated widely to health professionals and the public alike.”

“The at-risk population is already subject to the protections of our current policies: social distancing, medical attention for fever or cough. But there are several major problems with subsuming the especially vulnerable within the policies now applied to all.”

How Effective is Horizontal Social Distancing?

Currently, the "horizontal social distancing" approach being stressed by politicians and others assumes there will be a reduction of coronavirus community spread, reducing the peak in the number of cases and put less stress on the limited resources of the medical community.  

This is illustrated by the two charts uploaded as graphics for this feature.   You notice the number of cases doesn't change (the area under the curve) with either the horizontal or vertical approach.  But horizontal distancing has another issue:  it greatly extends the period in which society is affected by the disease.

The cost of social distancing is immense, something many politicians do not seem to have thought through. The lowest income folks are hurt worst, making "social distancing" highly regressive.   

Are the Media & Politicians Promoting Panic?

Throughout the past three weeks by exercising virtually unprecedented authority under the umbrella of a pandemic health crisis, government at all levels has assumed unprecedented control over our daily lives.

For politicians, there is the potential for endless attention, with opportunities to give sober pronouncements and promote increasingly harsh measures.  Resources become freely available from a worried citizenry.  And the situation provides fuel to attack political foes, as is apparent with the attacks on Trump  or Pelosi or Schumer for virtually every action they take.

The lack of testing is a massive failure.  There is, however, plenty of bipartisan blame to go around for ineffective responses.

For the media, the situation is a bonanza, with huge increases in attention, which promotes more "clicks" and revenue. An increasingly isolated and home-bound populace is glued to the constant media barrage, promoting fear and anxiety.   A highly connected population, unlike any population before, is unable to escape the incessant coronavirus coverage that is constantly featuring the latest death and shut-down.

A Better Way

Adopting a Vertical Social Distancing approach would take advantage of several unique and new aspects of the current situation:

• The fact that young and healthy people, the bulwark of our nation's productive capacity, are only minimally affected by the coronavirus.

• That most of the mortality is among the sick and elderly.

• That the technology to test millions of individuals quickly is available.

Perhaps these facts allow us to deal with the situation in a dramatically new and rational way. 

1.   Protect the most vulnerable with all available resources.  All nursing facilities, retirement homes, and the like would be essentially quarantined, with all patients and staff tested for the virus, with those testing positive isolated from the remainder.  All visitors would have to be tested.  All individuals who are over 60 and possessing serious health problems would be asked to self-quarantine, with food and other assistance provided to allow them to reduce contact with the outside community.

2.  Extensive random testing of the general population would be initiated, with millions of tests available for this purpose.  Such general testing would allow a determination of the extent of COVID-19 spread and the isolation of affected individuals and their close associates.  This is what I call "smart quarantine"-- the use of massive testing to identify the carriers and currently sick and to take them out of circulation.

3.  A fund to provide salaries for quarantined individuals would be initiated.  This would encourage all individuals to be tested and encourage financially marginal individuals to isolate themselves.

4.  Social distancing would end and all schools reopened within a month..   It is poor public policy to cripple education and the productive capacity of individuals that are the bulwark of the U.S. economy, particularly since most of them are not at risk for serious impacts of the coronavirus.  Sustained social distancing is not a long term solution.

The American people have a long history of panicking when they are threatened, at enormous financial and human cost.  After 9/11, the American people agreed to loss of privacy and civil liberties, and allowed a tragic invasion of Iraq.  After the attack on Pearl Harbor, fears of a third column led to the internment and loss of liberty of over 100,000 Japanese Americans.   

5) Never Give Up Hope.  There is some good news. COVID-19 may be more on the low side of these number ranges, because it might be so much more transmissible, and there might be more people that are asymptomatic and very mildly symptomatic. 

We are seeing good progress in medicine to treat it, and the infrastructure being rolled out to prep for a much larger impact.  Plus the lockdown actually IS effective, and we are just now beginning to see the growth rate decrease.  

There is also a  test for the antibodies being rolled out so we can understand how many people have already had it, and got over it.  Plus their antibodies are very effective at treating an infected person as well. If we know who is immune, our data gets much better, and we have a societal asset there to help fight this.  

Given all this, there is confidence in the hope that life will mostly return to normal by the end of the month.




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