Where do we go from here? New research and studies suggest next steps for fighting COVID-19

We’re no longer talking about whether to lock down to fight the COVID-19 outbreak; that ship has sailed. Now we’re discussing how long we need to sustain the lockdown, and when we might get to see our friends, co-workers and family again. Five newly-released research and study papers provide important insights into the answer.

The first two papers address head-on the question that President Trump raised last week: is the cure worse than the disease? Will the economic hardship that strict social-distancing measures impose cause more suffering than if we let the COVID-19 outbreak proceed without them?

One of the papers, written by a team at the Federal Reserve, found that pandemics do inflict lasting economic damage to economies, but those communities that implement interventions early and aggressively see that damage mitigated. Further, those communities are also poised for better and faster economic recovery after the pandemic concludes.  You can see in this graph that the U.S. cities that implemented longer interventions during the Spanish Flu epidemic of 1918-1919 (the green dots) had both lower mortality rates and overall stronger employment growth in 1919.

Part of this is obvious: higher mortality means fewer people to hold jobs. But the researchers found that the growth was persistent for the cities with aggressive interventions, and the economic decline was equally persistent (several years) for the cities that did not have aggressive interventions. The researchers also found that high mortality rates led to a persistent decline in manufacturing activity, so interventions that lowered mortality had a broad impact on manufacturing as well. As you can see in the graphs below, the cities with interventions had higher manufacturing activity and employment.

Because the data is so old, the researchers were not able to identify if specific interventions had more or less economic impact.

The second paper looked at pandemics similar to COVID-19 over the last 20 years. It found that GDP fell by 2.57% on average (across 210 countries) in the year the outbreak was declared, and five years later was still 2.96% below the pre-outbreak level. However, it also found that countries with more aggressive government-spending relief programs in the first year of the outbreak felt the downturn less.

Together, these two papers confirm for us that the right policy is aggressive and early measures to slow the spread of the disease, and aggressive and early fiscal stimulus to help the economy bounce back quickly.

That leads us to the next question: how long should the interventions be in place to slow the spread of the disease? A third paper tackles that, by trying to calculate the optimal length. It approaches it from a cold-hearted economist’s perspective, suggesting that the interventions should be in place until the cost to the economy to do so exceeds the benefits the interventions provide. And that math relies heavily on how you value the various benefits and costs. If strictly minimizing the mortality rate is the only measure, then the answer is simple: keep the measures in place for 18 months until we have a vaccine. But economic collapse also causes human suffering — and death — so even just looking at human lives, the calculus is challenging. In this case, however, the economists boil it all down to dollars: medical costs, the costs of lost productivity due to illness, and costs of human lives lost (known as the “value of a statistical life”). And they also take a swing at comparing the economic costs of intervention with the economic costs of letting COVID-19 run its course unimpeded.

They calculate as a baseline that with what we currently know about COVID-19, left entirely unchecked the economic cost of the pandemic would be $13.2 trillion — the vast majority of which is the cost of the lives it would take (estimated at 1.9 million). But with strong enough interventions to bring the reproduction rate of the disease (R) down to 1.0, it drops to $15.8 billion with about 2,300 fatalities. That, of course, is far less than the most recent predictions for U.S. fatalities — currently 100,000 or more. At that level, the cost would be well over $500 billion, but still much less than the cost of leaving it unchecked even in the cold, unfeeling world that economists inhabit.

But coming back to the original question — how long do we leave the interventions in place for — the researchers concluded that as the outbreak wanes the incremental value of sustaining the interventions quickly wanes. They estimated that if R can really be reduced to 1.0 through interventions, they should be sustained for 30 weeks, or about 7 months.

The estimated incremental savings for keeping interventions in place vs. lifting them if R can be brought down to 1.0. The blue line includes economic values for the human lives saved, using a traditional mechanism often employed by economists.

A fourth paper, commissioned by the American Enterprise Institute (and remarkably un-conservative for a publication from that organization), proposes a “roadmap to reopening.” It lays out four phases for the life cycle of the pandemic:

  • Phase I: slow the spread.
  • Phase II: state-by-state reopening
  • Phase III: establish immune protection and lift physical distancing (i.e. vaccinate everyone)
  • Phase IV: rebuild our readiness for the next pandemic

We are, of course, in phase I right now, and it lays out many of the things that we are trying to get competent at now: increasing diagnostic testing capability, keep the healthcare system functioning, increase the supply of PPE. But it adds two more, that are tied to the trigger for when we get to move to phase II:

  • Implement a comprehensive COVID-19 surveillance system so that we can continue to monitor the prevalence of the virus in the population. That includes serological testing for antibodies, so that we can understand the level of immunity in the workforce and the “herd immunity” protection that exists.
  • Massively scale up contact tracing and isolation and quarantine.  And this is really the key part: it’s what has enabled South Korea to escape the draconian lock-downs that many countries have seen, and is now enabling China to lift restrictions. The ability to quickly find, notify and isolate people who have recently been in close contact with a newly-discovered infected person is a game-changer in fighting COVID-19. The biggest challenge with COVID is that patients are contagious and actively spreading the virus for a period of time before they are symptomatic. That means that the only way to stop downstream infections (without locking everyone down) is to identify potentially infected people while they are still symptomatic and isolate them until they can be tested. South Korea has that ability. China now has it too — though it didn’t until recently, which is why it locked down the whole country.

The trigger for moving from Phase I to Phase II is precisely this ability to quickly test people at large scale and on demand, trace the people they have been in contact with for those who test positive, and isolate and test those contacts. The bad news is that we’re not even close to having it now: we have missed the boat on large-scale testing, and we have no infrastructure for contact tracing at scale (ideally that would leverage a national healthcare system like most developed countries have).

The fifth paper addresses that issue, dives deep into the timing of the incubation, contagion, and symptomatic phases of COVID, and concludes that it’s impossible to contain this virus through manual contact tracing. It does an interesting analysis that subdivides R into the parts attributable to the pre-symptomatic and symptomatic phases a patient would experience, as well as to asymptomatic carriers and to environmental infections. They conclude that 47% is pre-symptomatic patients; that means that if R is above 2.0, the infections from pre-symptomatic transmission alone are enough to sustain the pandemic. That is far too high to be controlled without advanced contact tracing.

The reproduction rate R for COVID-19, broken out and attributed to different sources.
Transmission of COVID-19 associated with pre-symptomatic, symptomatic, and asymptomatic persons, as well as with environmental transfers.

Their solution?  “There’s an app for that.” Well not yet, but they argue for creating a mobile app that during pandemics could automatically track your location and help to quickly identify close contacts who need to be notified if you test positive for the disease.

There are obviously two problems with this. The first is privacy: it’s bad enough that cell phone companies keep location data on us, and that we allow many social-media apps to also gather that information. But allowing a large public-health agency to collect everyone’s location data in order to enable this kind of instant contact-tracing is a scary proposition.  The second issue is equity: not everyone has a mobile device that could run such an app. A public health system that leaves them out perpetuates the existing inequities in health outcomes in our society.

Nevertheless, the last two papers raise a good point: the U.S. doesn’t have what it will take to get out from under draconian social-distancing interventions before a vaccine shows up. Once we get past the peak in this first wave of COVID-19, that will be the next order of business. It would be nice to think that some people could go off and work on that problem now, but by all appearances it’s going to be “all hands on deck” just to get us through the next 6 weeks.

The big takeaways from this recent research:

  • While quick, aggressive interventions to stop the spread of COVID-19 inflict economic pain, it’s far better than the alternative of letting the virus run its course unchecked.
  • Quick, fiscal stimulus in the first year of the outbreak will make a big difference in the economic outcome.
  • We’re going to be under aggressive measures to keep the virus contained for several weeks, if not months — but it will still be worth it.
  • The path forward involves wide-scale deployment of rapid testing and contact tracing — but we don’t have that capability today, and it’s going to be very difficult to build it out given the current state of the U.S. healthcare and public health systems.

I hope you found this article valuable. If you did, please take a moment to make a contribution to support my ongoing work. Thanks!