now what?

[calimac]

What's really unclear to me, as it was with the invasion of Iraq, is: what's the endgame here? What are we trying to accomplish, and what will constitute accomplishing it?

It's clear enough that all these societal shutdowns are intended, not to stop the virus, because it's already embedded too much in the population to make that feasible, but to slow the growth of infections enough to keep the hospitals from getting overwhelmed when people start getting sick. But how long do we keep having to do this? Until everyone's exposed to the virus, despite our attempts to keep them away? So ... the better we are at this, the longer we'll have to keep doing it?

And how long will that be? Months, I'd think. Most arts groups I follow started with cancellations through mid or late March and then extended it to the end of April, with no promise it would stop there. One federal health official suggested a complete lockdown of society for two weeks, but that only makes sense if we assume that everyone's already infected and we're just waiting to see who gets sick, and I doubt that's the case.

Maybe the virus will slow down and get sluggish during the summer, as the flu usually does, and people can peek their heads over the parapets and go back to doing a few normal things. But if that's all that happens, it will come roaring back in the fall, probably worse than ever, which is what the 1918-19 pandemic did. And we'll have to go through the whole weary round again, until a vaccine is ready the next year. And will that clamp it down? And what if acquired immunity is only temporary, as it usually is for similar viruses? The 1918-19 pandemic ended when the virus mutated away from more deadly strains (because they killed their hosts too efficiently), but this virus, while deadly, isn't that deadly, so it's not under so much evolutionary pressure.

In the meanwhile, what about commerce? Some cities are shutting down restaurants. Despite one news report saying California is doing it too, it isn't: the governor says food service remains vital. Of course that may change at any moment, as so many other declarations have. I think I read that some European countries are closing all commercial outlets except groceries, pharmacies, and banks. That may be feasible for a short period, a couple weeks maybe, but after that too many urgent needs of daily life that can't be handled by delivery or mail-order will pile up; I won't name any, because you can too.

Comments

[lydy]

As I understand it, we're buying time. A vaccine will probably be available in a year to 18 months. The health care profession will get better at treating the disease. Meantime, we're trying to reduce the strain on the system so that people don't die while we figure that shit out. If what needs to happen is that everybody needs to get the virus (for generous but not absolute values of everybody) it still makes sense to have it happen a little at a time. A steady stream of sick people is much more manageable than a sudden spike. But, mostly, we're trying to buy time because there is so much we don't know. The reason there isn't an endgame is because we don't know enough, yet. I mean, I suppose the endgame might be 2% of the world population dies. I do hope that's not it. But at the moment, we're trying to buy time.

[calimac]

You keep saying we're trying to buy time, but I already understand that and specified it to begin with ("all these societal shutdowns are intended ... to slow the growth of infections enough to keep the hospitals from getting overwhelmed when people start getting sick"). What I want to know is, what will having bought the time consist of? At what point (and I don't mean a date, I mean what will functionally have happened) will we say we've bought that time? Insofar as what you say means anything in response to that question, we're going to have to hold out until the vaccine is ready. So ... complete social shutdown for 18 months? Is that it?

[lydy]

I'm sorry I wasn't clear. There isn't an endgame yet because we don't have enough information. There are some things that are clearly on the horizon, like a vaccine, and some possible improvements in care, but at this point, there isn't an endgame because we don't have enough information. Everyone is hoping that it isn't a total societal shut down for 18 months. I'm not sure the world economy can actually survive that. But in the mean time, we're all trying to give the professionals some space to make some good decisions. It's especially hard in the US because it is impossible to trust our national leadership. But, well, mean time, we're all just trying to not die, I guess.

[calimac]

Let me try rephrasing the question again. We're shutting down until $SOMETHING happens. What is the $SOMETHING? There has to be something to fill in the blank.

[lydy]

The dramatic reduction or cessation of community spread.

[calimac]

But the reduction of community spread could be caused by a sufficiently rigorous shutdown. We probably won't get that, but let's say we did. Then we ease off the shutdown, and the spread of the virus starts speeding up again.

So I don't think that's it. Without that, then, the reduction or cessation of community spread would be because the virus has already become functionally universal, which is an endgame I discussed in the original post, with problems as an endgame that I also discussed there.

So is that what they mean? Are they expecting us to live this way for an indefinite number of months, probably at least three?

[lydy]

The presumption is that a person who has had the virus, and who recovers, is not a vector of contagion, right? So, everybody retreats to their separate corners. Those who have the virus who are not very sick get better, and stop being a vector of contagion. Those who are very sick get treated, get better or die, and either way are not a vector of contagion. Those who are well are not exposed to the virus, and neither spread it nor contract it. So, the disease runs its course in isolation, and no new cases are created. So, if in a month, there are very few if any new cases, and everybody has stayed away from everybody else, we have three sets of people: 1) dead people, who are not a vector, 2) people who have had the virus, gotten better, and are not a vector, and 3) people who have not had the virus, do not currently have the virus, and are not a vector. But as long as people are out and about, trading microbes, the virus continues to spread, and the number of serious cases that needs to be treated in hospitals continues to rise. The point is to stop at whatever the amount of infection we already have in the the population. We know that things are getting better when the number of new cases drops dramatically. So, again, the end point is when new cases drops dramatically or stops all together. Since the incubation period is about 14 days, a month of very few new cases is probably enough.

[calimac]

So long as people can be contagious without any symptoms, unless we keep everybody in complete isolation for an entire incubation period (which we only think is about 14 days, we're not entirely sure if that's always the case), it will still be possible for the disease to spread.

[lydy]

So I guess I'm really confused about your question, then. Are you asking about what the end game is, or are you asking for security and certainty? Because the former is massive drop in new cases, and the latter is just not possible. Infection is always a numbers game. You wash your hands, not because it will 100% eliminate all possibility of the virus living on your hands, but because it significantly reduces the microbes on your skin and reduces your total chances by a measurable amount. It's not perfect, but it's enough to matter. You ask people to socially distance, and you put in place things that enforce that like closing restaurants, bars, and schools, not to create a 100% reduction in transmission, but to significantly reduce it. And so on. This is and always was a numbers game, with huge amounts of uncertainty. And the reason for social distancing is, as you say, because of asymptomatic transmission. It helps, but it's not a panacea.

[calimac]

This is why I compared it with Iraq. They thought they had an endgame, but they didn't. I'm not sure if these guys do.

[calimac]

First, it would take massive—and probably unrealistic—control measures to get R0 so low. Second, the economic cost of full suppression is likely to be very large in the long term. Third, the control measures would have to be in place for the entire population for well over a year. Until then, if the control measures fail at any point, the epidemic will almost immediately come roaring back because no one has developed any immunity to it.

No, I don't think I'm asking for anything beyond the end game.

[wildeabandon]

I think to some extent $SOMETHING is that we get more information and can figure out what the best endgame is and how to get there. We figure out which restrictions have the best ratio of "reduction of spread"/"harmful social impact". To some extent it's that we manufacture more ventilators.

[calimac]

That could be, yes.

[sartorias]

The something I suspect is people RECOVERING from the virus. If they do, I expect the general population to shrug and say, oh, it's just another flu/a [insert pejorative here] hoax, etc. and go back to As You Were.

If people start dying in huge numbers, then we get infrastructure collapse, etc, etc. Huge cities are so very fragile.

[lydy]

Most people will recover, it looks like. I think that if you've had it, and recovered, not only do you not get it again (probably) but you aren't a vector for other people getting it, right? So, as people recover, they stop being vectors? I mean, I do think we want a better plan than "everybody get sick, 2% of you die," which is the herd immunity approach, maybe?

[sartorias]

I expect that's what we might end up with. Around me so many small businesses, hurting before, are now failing: if there is no work, there is no pay. They will want to get back to normal ASAP. Then there's the inertial velocity factor, schools will shift back into normal mode (maybe, though some might develop in the online direction), etc. Entertainment gatherings ditto.

[voidampersand]

The immediate goal is to prevent large numbers of people from dying now. When the virus spreads rapidly, the health care system is overwhelmed and thousands of people die. Social distancing is proven to reduce the death rate. At this point it is not possible to stop the virus. That is not a goal. But it is possible to dramatically reduce the death rate. It is without doubt an ethical imperative.

In the meantime, clinical trials are going on for anti-viral drugs, and trials are starting for vaccines. The ultimate goal is to keep as many people as possible alive until effective medications and vaccines are available. That does offer a hope of stopping the virus, or at least getting so it is no worse than the seasonal flu. Probably not this year, but in two years it is likely.

[calimac]

By that argument, we're all going to have to shelter in place for two years.

[voidampersand]

Actually, no. The shelter in place policy is to prevent the health care system from being overwhelmed now.

If you want to know how long this will go on, or how things will be two months from now, the answer is that nobody knows yet. It is a novel coronavirus, not one that is already well known. Expect policies to change, sometimes rapidly, as more is learned.

[calimac]

Actually, yes. I didn't say that was the reason for the shutdown, but if that reason is to have any force or effect on the health care system overload, it's going to have to be in effect for the next two years. See here and here.

"Expect policies to change, sometimes rapidly, as more is learned." Indeed. And (see above) we've already learned enough to know that a 3-week policy of such weak restriction is a drop in the bucket.