How to emerge from the COVID-19 lockdown quagmire
The reason I hate the word lockdown as used in Western nations is because it is a nebulous term that has been used to mean vastly different things in different countries (e.g., UK vs France), and even different things in the same country as time has passed (e.g., Italy and Spain during March). It has been about a month now since COVID-19 has led to some degree of restrictions across Western nations. There is no doubt that Europe has been the undisputed center of the pandemic during this period, although the US might eclipse the number of deaths per capita compared to Italy, Spain, France, and UK in the coming days. This is despite the fact that these countries had at least all of February to prepare for the disaster ahead.
Governments in multiple Western nations (e.g., most of Western Europe and the US) have taken the approach of “flattening the curve”. See my previous post of why I consider this a government strategy of creating low expectations that they can meet more easily, instead of actually trying to protect its people like South Korea did. After creating this easier challenge for themselves, they are now asserting something along the lines of: “We have done a very good job with the lockdown. The lockdown has been successful. We are now at or past the peak of the pandemic. We can start thinking of relaxing restrictions in May or June at the latest.” This makes me ask: If you are going to relax restrictions, how will the number of deaths not rise? Herd immunity, which has obviously not been reached? Vaccines or therapeutics, which are clearly far from approval? How can you possibly claim the worst is behind us without some change in public policy to compensate for the reduced social distancing?
In the spirit of not just being a critic of governments but actually proposing solutions, I am writing this post to enumerate my ideas regarding an effective social policy to limit loss of life without destroying our way of life. I do not intend this post as the final word, but as a mechanism to promote discussion of ideas that will survive a cost-benefit analysis relatively unscathed, especially compared to the current policy, regardless of which Western country you use as benchmark. If you think everyone can stay the fuck home for 18 months (common estimate of how long a vaccine will take), or even 1 month, you are either privileged or ignorant or both. I stress that my proposal is targeted towards Western nations, and is not feasible for poor or technologically limited countries.
All relevant governments should be seriously considering my proposal below as the only sustainable strategy, and they need to be cognizant of the needs of those economically at risk before enacting any policy. During the time it takes to implement the changes I propose below, current restrictions should continue. The implementation of my proposal requires that every individual has a smartphone that they are legally required to have on or near their person at all times. Anyone who does not have a smartphone will be given one. Anyone too old to use a smartphone will be considered to under the restrictions of point (1) of my proposal. A quick definition: by quarantine, I mean no going out for any reason whatsoever.
(1) Quarantine high risk people indefinitely with government enforcement and government support (high risk determined based on age and preexisting conditions). Initially, when a good predictive model that incorporates preexisting conditions has not been created, age alone can be used as a predictor. The threshold of what is considered high risk can be altered based on how busy hospitals and ICUs get (initially I would choose those with top 25% risk, and then quarantine fewer and fewer on a weekly assessment). Enforcement means digital surveillance and police/military issuing fines and applying force if needed. Support means free groceries delivered to your home by the government, 100% unemployment benefit (since most high risk people will be on pension, no unemployment benefit will be needed for most people in this category), free high speed internet (for video calls), free full-time carer (who is also indefinitely quarantined) for those unable to care for themselves and living without family. In case you are wondering why I want the government to deliver groceries to quarantined individuals, rather than quarantined individuals having to figure out online delivery options from the supermarket, it is because (a) supermarkets simply do not have the capacity to deliver to so many people, and (b) it may be technically challenging for the elderly to figure out the online ordering process.
This first point can be referred to as cocooning. You might mistakenly think that this has already been tried in the UK or at least studied by academic advisors of the government. But the UK simply sent letters to at-risk people and merely suggested how people should act. There was no government enforcement and government support that is essential for this point to be effective. Anyone above 80 years (this number is debatable, but there has to be a number) is allowed to opt out of this first point if they sign a disclaimer saying they are OK with dying (basically a DNQ, i.e., do not quarantine). The reason this caveat is needed is because there could be people who were near death even before the pandemic started, and they should get to decide how they want to live their final days.
(2) Quarantine symptomatic people for 2 weeks with government enforcement and government support (without any test of what is causing symptoms). Symptomatic means anyone with a persistent cough/sneeze or a runny nose or high temperature. To decide who is feverish when in a public place like a school or office or supermarket, there should be thermal scanners at the entrance (already available in many international airports). Other symptoms can be determined based on human observation (teachers, coworkers/managers, cashiers, and security guards) and CCTV with audio capability if needed (the technology already exists and only needs widespread deployment). I realize that because of the broad nature of such symptoms, this restriction will ensnare people with common cold or flu (who should not be spreading their germs anyway) or even people with seasonal allergies. For hay fever sufferers, they make up less than 10% of the population, and most of them will be symptomatic for less than a month, so this is not a costly intervention, especially compared to the current blanket lockdown approach.
Enforcement means the same thing as in point (1) above. Support means free home-delivered groceries and fully paid sick leave. Most countries have limited testing, and often such limited testing takes up critical resources like hospital space and personnel. Plus false negative of RT-PCR remains a huge problem. Symptomatic people should be given priority for remote consultation with a doctor, in case they are suffering from conditions that can benefit from a drug (e.g., antibiotics for a bacterial infection). Once the symptoms cease, the person will be given an antibody test to determine if they really had coronavirus. If symptoms get worse, consider points (3) and (4) below. Unlike point (1) above, there is no situation in which this group can violate quarantine.
(3) Discourage people from visiting hospital unless they feel their life is at risk. There should be government apps with a short questionnaire to determine if they need to go to hospital. Before an effective questionnaire is created, people should be discouraged from visiting the hospital unless they are experiencing shortness of breath, and they should be reminded that shortness of breath does not mean a stuffy nose. A huge fraction of those visiting hospitals are not getting admitted. These time-and-resource-wasters need to be stopped. As you probably know, anyone showing up at the hospital needs triage, i.e., have risk assessed to decide course of action. This is not an easy task at the best of times. This problem is magnified during situations of high case volume, high stress, and exhaustion, i.e., now. I know fear of death is a natural instinct, but this has to be informed by reason. Death from COVID-19 is not like death from a heart attack or a stroke. It does not sneak up on you. If you are under 50, unless you see that your breathing trouble is persistent, do not go to the hospital. Some are being admitted just to be given oxygen. For them, consider point (4) below.
Most importantly, people should be told that visiting a hospital to get a coronavirus test in the absence of severe symptoms is not acceptable. Under ideal circumstances, what can prevent this outbreak is widespread testing, contract tracing, and strict isolation. These are not ideal circumstances. Hospital resources are stretched to the limit in many places. The place to do widespread testing is not a hospital that is desperately trying to treat patients. If a country or region has set up separate testing facilities, has figured out a way to perform such testing without making you queue in a line, and has enough spare nurses to administer these tests and enough resources to analyze them, then I am all for widespread testing. But with a few exceptions like South Korea, this is not the case. So if you have the symptoms of persistent cough and/or fever, but do not have sustained breathing problems, you do not need testing to know how to act. If you have mild symptoms (persistent cough and/or fever), act like it is the coronavirus, rather than thinking it is the flu or a cold.
(4) Offer the opportunity for home care: stockpile oxygen tanks and oxygen masks in each city, which get distributed via government hotline and app, with in-home installation and coronavirus testing. A wrinkle in this home care idea, is the so-called cytokine storm. There are existing drugs that might stop this storm. Phase III trials should start for these drugs immediately. In the interim, those getting oxygen tanks for home care should also be outfitted with heart rate monitors, and an ambulance should automatically be called when the monitoring detects something abnormal.
(5) For the rest: back to school and work. For people who can work from home without loss of productivity, they should continue to do so, even if this is for a certain fraction of work days (say three days from home and two days from office). No more crowded spaces (e.g. theaters, arenas, bars) till vaccine. A three-foot distance should be maintained in all public spaces, which is more than enough for people who do not cough or sneeze. Shopping malls and restaurants can reopen if they can achieve this three-foot distance requirement. As previously mentioned, symptomatic people will be under enforced quarantine, and there are no studies talking about asymptomatic spread beyond 3 feet. Asymptomatic spread itself is about 10% of current transmission. The absolute number of asymptomatic transmissions will reduce when (1)-(5) get enforced.
(6) Ban all travel to and from countries not following this protocol: This is extremely important because even South Korea has had scares about a possible resurgence because of “imported” cases. Singapore, which was doing great in the early days, is also having problems for the same reason. This will undoubtedly hurt the airline industry. But instead of offering support to the industry in the form of a bailout, governments should be paying 100% unemployment benefit to all staff (pilots, flight attendants, ground crew). No airline company is indispensable. But the staff need to be cared for, and the planes can be bought back if a company folds. There will also be a negative impact on the tourism industry, but this can be greatly ameliorated by a spike in domestic tourism.
(7) The only part I have not figured out is public transportation. Maintaining even a three-foot distance in public transport is impossible. For anyone who can commute to work on foot, this is not a problem. For anyone able-bodied, walking 3 km or maybe even 5 km each way should be a reasonable amount. For those who are within biking distance of work, a free bike should be provided if needed. Public transport should be running at the highest frequency possible, to reduce how crowded vehicles get. Let us not recreate the stupid actions of the London Mayor. Everyone on public transport should be required to wear a mask, even though masks are not perfectly protective, and are even less effective when used incorrectly. Steep fines should be imposed on those not wearing a mask inside public transportation.
For those who have managed to read this entire post, I thank you. I realize there might be several points on which you disagree with me. If you have an alternate proposal that can be maintained for a year without destroying mental health of vast swathes of society and making unemployment go to 30–50%, please comment below. More likely, if there are minor points you disagree with and have a viable alternative, I would be very happy to hear from you. If there are inaccuracies in my logic, I would love to know what they are. I do not intend to act as if I have all the answers. But I am certain that what I have proposed here is better than what is currently being done, and I ask for your help to spread my message to start a widespread social dialogue.
