The 4 paths out of Corona-land (and why we will be living here for the next 2 years)
Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning — Winston Churchill
With the biggest hotspots of the Covid-19 crisis, New York, Italy, and Wuhan, all starting to subside, and large parts of Europe and the US entering the process of reopening, there is a lot of talk about life returning to “normal.” VP Pence has predicted that “by Memorial Day Weekend we will largely have this coronavirus epidemic behind us,” and his optimism seems to be reflected in the stock market’s jubilant bounce-back over the past month. Unfortunately, this can’t be true, and instead, we are going to spend at least the next 18–24 months in some sort of Covid-purgatory, where we find ways to live with the constant presence of the novel Coronavirus.
There are only 4 possible paths our of Corona-land, and none of them can be reliably expected to take less than 2 years, and may take much longer. Specifically they are:
- Medical treatment,
- Vaccination, and
- Herd immunity
To take them in turn, both mutation and medical treatment are extremely unlikely to bring Covid-19 to an end, ever. Having the novel Coronavirus mutate into a mostly harmless strain, and for that benign variant overtake all its more virulent cousins would be wonderful, but it’s a deus ex machina that we can’t expect. Having a medication that would quickly and easily treat the disease would be almost as wonderful, but it’s highly unlikely. There are currently no fast acting curative anti-viral medications. None. Anti-virals are the world’s worst drug class, and we can’t expect a medication developed emergently to perform qualitatively better than any similar drug to come before. Medications like remdesivir and (maybe) even hydroxychloroquine may somewhat lessen the severity and mortality of the disease, but there will be no magic bullet.
The next possible way out is through a vaccine. Anthony Fauci has been touting the “12–18 month” goal since early in the pandemic, and the White House’s “Operation Warp Speed” is hoping to accelerate that even further. What neither of them fully acknowledge is how big a shift this would be from the way any other vaccine has been developed and rolled out, ever. 5 years is generally considered a “fast” time for vaccine development, especially when you consider that in order to release a vaccine for general use, you need to:
- Prove safety,
- Prove efficacy,
- Manufacture in quantity, and
- Distribute and administer the vaccine
All of these are hard, and can only be rushed so much. Vaccines are potent immune-modifying compounds, and if not adequately tested can have serious side effects, or even be actively anti-protective, causing increased susceptibility to a disease. There are a large number of vaccines under development now, and hopefully at least one of them will eventually be shown to work. But right now the “leading” vaccine has its status based on trials in 6 monkeys. That’s right, 6 monkeys. While signals of a vaccine’s effectiveness come relatively quickly, safety takes longer. Imagine a vaccine that reasonably prevents Covid-19, but kills 1% of patients a few months in. Such a vaccine would be more deadly than the disease itself, but that would only become apparent after testing the vaccine in thousands of people, over several months.
Combined with the challenge of mass producing a product that has to be grown in chicken eggs or live cells, and then often transported by cold chain prior to administration to billions of people across the world, 2–5 years seems like a much more reasonable goal. The Gates Foundation is “all in” trying to move faster, but Bill Gates acknowledges that even making an 18-month timeline is an ambitious moon-shot.
And finally herd immunity, which kicks in when somewhere between 60% and 80% of a population are exposed and develop an immune response. This is the idea behind the “flatten the curve” concept we’ve all grown so tired of. The past few weeks have proved that good social distancing work to flatten the curve in even high population density areas, and that the curve is in fact already relatively flat in lower-density environments.
The implication of that, however, is that getting to the other end of the “curve” will take a long time. In the US, New York City has the highest seroprevalence (a measure of how much of the population is exposed and immune) at 21%. That means that New York City has to go through what it’s already done two and a half times over in order to get to herd immunity.
The balance of social distancing and economic loosening that will be required and the shape of the curve in different environments will be the subject of another post. But it won’t be fast. Anywhere the infection rate goes too high, the experience of death and disease drives social distancing which brings the disease (temporarily) under control, which both prevents the whole world from looking like Elmhurst at the same time, and ensures a prolonged course for society. With US national seroprevalence likely in the 4–6% range, we are less than 1/10 of the way down a path towards herd immunity. The process is so nonlinear that it’s difficult to project forward, but I see 18-24 months as a minimum time course, and it could go out longer than that.
The implication of all this is that Covid-19 will be with us for a while. While some small sophisticated islands and like Singapore and New Zealand may be able to sustain a disease suppression strategy, the rest of us will have to find ways to live and economically survive together with the novel Coronavirus until the end of 2021, at least. More on how we do that, and what it looks like, in a following post.