WE ARE FAILING AT COVID-19 BUT WE CAN EASILY SUCCEED

We are failing COVID right now. That’s killing people and our economy. We don’t have to be failing. We can beat COVID. Let’s be smart and beat COVID.

INTRO:
The United States is failing COVID. Other countries are getting their case counts down, saving their citizens lives and health and reopening their economies. America is falling farther and farther behind.
It’s a tragedy both in terms of the loss of life and health as well as the potential massive economic damage that not having a secure public health system will cause.
If the vaccine doesn’t come in early next year and COVID drags on, Americans will have to quarantine before entering other countries and, eventually, people will locate their businesses elsewhere because nobody wants to be located somewhere that will inconvenience and possibly kill their employees.
I think that one of the main reasons that we are failing is that we simply do not understand the situation.
This is what I think is happening and what I think we should do about it.

WHY THINGS ARE NOT AS BAD NOW AS THEY WERE IN MARCH
WHY THINGS ARE STILL PRETTY BAD
WHY HERD IMMUNITY IS AN INCREDIBLY STUPID ANSWER
WHY DOES IT MATTER THAT THINGS AREN’T SO BAD?
HOW DO WE ACCOMPLISH THIS?
WHY WILL THIS WORK?
WHAT WOULD THE FUTURE BE?
WHAT ISN’T HAPPENING RIGHT NOW?

To understand this post, you need to know what R is. R is the effective reproductive number of a virus. Given 100 cases, how many new cases will those 100 infect? If the R is 2, then those 100 people will infect a total of 200 people. That doesn’t mean that every one infects two people, it means that is the average.
The R changes based on what people are doing in a community. If nobody is doing anything to prevent transmission, the R is higher than if people are wearing masks and social distancing. Every community has its own R. All the R estimates in this post are taken from https://rt.live/.

WHY THINGS ARE NOT AS BAD NOW AS THEY WERE IN MARCH
First, it’s super important to understand that, even though cases are surging in the US, it’s not like what was happening in March.
As of June 26, based on case counts and R, the worst state in the US is probably FL. Based on the seven day average, they have about 30 new cases per day per 100K of population and the R is around 1.4. (Nevada and Montana both have higher R, but their case counts per 100K are much lower.)
At an R of 1.4, new cases double roughly every 8 days. (A generation for COVID is about 4 days, at 1.4, cases double about every 2 generations.)
Florida’s R has been 1.4 for almost the entire month of June, so it’s daily case average has gone from 650 to 1300 to 2600 to 5200 in 24 days (6 generations = 3 doublings).
In March, based on case counts and R, the worst state was NY.
For the sixteen days between February 24 and March 12, New York’s R was between 3.5 and 2.5. For simplicity, let’s just imagine that it was at 3. At an R of three, cases double every 2 days. So, in those 16 days (8 doublings), New York went from 400 daily cases to 100,000 daily cases. (It’s a guess based on death data. The precise number of cases will never be known, but the proportion is probably right).
Again. With an R of 1.4, Florida’s daily case count has increased by 8x in 24 days. With an R of 3, New York’s daily case count increased by 250x in 16 days. R=3 is much, much, much, MUCH worse than R=1.4.
So, we are nowhere near New York in March. Nowhere near it.
The people that are saying that something must have changed with the virus because not so many people are dying in the Florida spike simply don’t understand that, compared to the NY spike, the Florida spike is a little bump.
It’s important to note that New York is the worst, but not the only state that had this kind of outbreak.
Louisiana had approximately 5 doublings from Feb. 28 (when the R was 3.2) to March 14 (when the R was 2.1). That brought case counts in our tiny state from ~300 to ~4500. That’s 15x in 16 days, compared to Florida’s 8x in 24 days.

WHY THINGS ARE STILL PRETTY BAD
The problem with Florida’s somewhat rosy picture is that if you just let an R of 1.4 roll, you start to see pretty big increases after a while. So, in 8 more days, FL will have daily case counts of 10,000 per day. In sixteen more days, it will be 20,000 per day — that means that Florida will be seeing ~200 COVID deaths per day a few weeks after that. And, even if you get the R to drop at that point, you will still have weeks of five figure daily cases.

WHY HERD IMMUNITY IS AN INCREDIBLY STUPID ANSWER
Some people are thinking: So what? This virus isn’t that bad. Let’s just get to herd immunity and get it over with.
Herd Immunity is a stupid idea. There are tons of reasons why, starting with the fact that we don’t know how long immunity lasts so it might be completely impossible. And it would mean close to a million deaths in the US, in the best case, so not so nice.
But even assuming that there is long lasting immunity, and we can live with the deaths, let’s walk through what it would take to get to herd immunity in FL.
Scientists say that FL needs around 12–14 million infections to get herd immunity. But, let’s assume, for a complicated reason, that they are wrong, and you actually get effective herd immunity at 8 million infections. So, 8 million people get infected, around .5% of them die (we are being super generous and hoping that Florida is able to protect its vulnerable, somewhat), so 40,000 people in Florida die and Florida has herd immunity.
How long does it take to get there?
If the R proceeded at 1.4, it would take 8 doublings, or 64 more days. That means that Florida would hit herd immunity in about two months, just in time for football season and the RNC. Doesn’t sound so bad, right?
But, the “problem” is that people are not going to die so cheerfully. So, what actually going to happen is that things are going to get completely out of hand at around doubling number 3(the end of July), when 80,000 people per day are getting infected in Florida, and three to six hundred per day are dying. At that point, people in Florida will be petrified, hospitals will be swamped, and, people are going to stay away from other people because they will be terrified. So, the R will drop. And when the math is done, it will come out that Florida is still only at about 1 million total infections (5–10,000 dead), and is very far from herd immunity.
What a “shame”! If we could only bite the bullet and ride it out for another month (four doublings), we could get to herd immunity. But, it’s simply impossible to imagine. So, the cycle will repeat itself. It will take another 3 months to get the next million infections, and over and over and over — so it will take about 2 years to actually get to herd immunity.
(If you are questioning the 2 years math, keep in mind that a population where five percent are infected will have a slightly lower R than a population where there are no infections, all other things being equal. As the percentage of the population that is immune grows, the R drops so each cycle will take longer)
At the end of two years of misery, Florida will have the 40K deaths, the hundreds of thousands who were seriously ill and the economic disruption of 2 years of fighting COVID. But they will have herd immunity.
Like I said, Herd Immunity is a really stupid idea. (And this was with some very generous assumption about death rates and a lower herd immunity number.)
Just drop herd immunity — it’s a bad, very bad, dumb plan that should not be contemplated.

SO WHY DOES IT MATTER THAT THINGS AREN’T SO BAD?
Because an R of 1.4 means that we are so very close to solving it. It means that despite all the crazy things that Floridians are doing, the few things that they are not doing (gathering in large crowds indoors for basketball games and concerts, some people wearing masks, etc.)is enough to get the R down from its “natural” place of ~2.5–3 to 1.4.
That means that even Florida just needs to reduce transmission by about one third to get the R below 1 and see a steady drop in cases.
It’s really not that hard to imagine happening — just eliminate 1 in every 3 infections, and you save thousands of lives.
Louisiana is much better off (probably mostly because around 10–15% have already been infected, so the virus will spread more slowly here).
Louisiana’s R is around 1.14, which means a doubling every ~3 weeks or so. All we need to do is reduce transmission by 15% and we get the R below 1 (.9). That means that all we need to do is stop one out of every six infections and the virus will “magically go away on its own” in Louisiana. Admittedly, it would take a very long time to go away if we just get the R down to .9. But, imagine that we stop one out of every 3 infections, and get the R down to .75. The virus would go away very quickly.
Watch:
Louisiana is currently averaging 3200 cases per generation (4 days). At an R of .75, that goes to 2400, then 1800, then 1350, then 1000, then 750, then 600, then 450, then 320, then 240, then 180, then 135, then 100, then 75, then 60, then 45, then 32, then 24, then 16. At 16, there is a better than 50% chance that it goes to zero the next generation. That’s 10 weeks and the virus is gone from Louisiana. And that is with us doing only enough to stop every third infection that is happening now.
What if we stop half of the infections? Well then we could go to less than 20 cases in 10 generations, around six weeks.

HOW DO WE ACCOMPLISH THIS?
We could get the R below 1 by re-instituting the lockdown. The R of EVERY SINGLE STATE in the US was below 1 on April 30. If we went into lockdown again, and everyone took it seriously for around 2 months, the virus would be gone. But the problem is 1) that is not happening. 2) that will kill a lot of people. 3) It will cost trillions of dollars and 4) As soon as the lockdown is lifted, if a single COVID outbreak happens anywhere in the US (And they will happen, because people will come in from other countries), we are back to square 1 without a plan for dealing with COVID outbreaks without lockdowns.
So, how do we deal with it, without a lockdown? The answer is simple. Effective contact testing.
Now, you are probably saying: We are already doing Contact Tracing. But, the problem is that we are failing miserably in our contact tracing. Why? Because we are not thinking about it in terms of what we need to accomplish.
Remember, all we need to accomplish is reducing half of all infections. Even in Florida, where the R is 1.4, eliminating half of all infections would get the R to .7 and the virus would eventually (after about 4 months) go away.
But, every contact tracing effort that I know of contacts people and says to them that they should get a test AND THEN REMAIN QUARANTINED FOR 14 DAYS EVEN IF THE TEST IS NEGATIVE.
Not surprisingly at all, those efforts are failing. Frankly, I would not comply with a request to test and then quarantine for 14 days for a disease that I probably don’t have. And I can do a lot of my work remotely.

But, But But, the tracers blubber, tests sometimes give you false negatives. And, some people don’t display symptoms for 14 days.
The answer to that is: WHO CARES? We are not trying to stop every infection with contact tracing, we are trying to reduce half of all infections.
When you tell people that they have to quarantine for 14 days even with a negative, most of them won’t do it. If you told people that it’s a negative and you are out, you would get compliance way up. And if you sweeten the deal with a little cash, you get compliance even further up. The current tracing system is probably 80% effective at stopping transmission, but only 25% compliant. That means it is getting around 20% of what China’s contact tracing does. (phone apps, government mandates and prisons for people who don’t comply). What if the system was only 60% effective at stopping transmission, because sometimes it let a false negative walk who also developed symptoms very late? But, it was 90% compliant. That would be 54% of China, and we don’t need much more than that.
Close your eyes and imagine a scenario where every 15 minutes, TV, radio and internet ads told you “if you have been exposed to someone that is infected, go get a COVID test. It will only take an hour. Just go get a COVID test and you will get a $20 bankcard, to thank you for being a good citizen. If you are negative, you won’t have to worry. And, if you are positive, you need to quarantine until either 14 days or no symptoms and you will get $50 a day for quarantining.”
Imagine if every person in the US knew that they could get a COVID test for free, plus $20, in an hour, if they have been exposed to COVID. If they are positive, they get $50 per day for being a good citizen and isolating for 14 days or until symptoms are gone. Compliance for contact tracing would be at >90%. People would happily answer the calls of contact tracers, because they know that it means free money. Plus, even if they are positive, in most cases its no big deal, just stay home for a week or two you make $350-$700.

You might be thinking that this is a huge waste of money. Hundreds, thousands of people will show up to get tested. SO WHAT? Think about it. Even if the test costs $10 and the test “sweetener” is $20, you would still end up ahead, because your number of tests would be going down as cases drop, instead of going up. If Louisiana cases double in the next three weeks, then double again, then double again then double again, that’s 52,000 cases = 52,000 tests. And lets say we test 10 negative contacts for every positive. That’s around 500,000 tests, or $5 million.

But, if we do the right kind of contact tracing and the R drops to .6, then we end up having only 5000 cases (and COVID goes away after ten weeks). Let’s say we are testing 40 people for each positive, that’s 200,000 tests — at $30 a test, you are only spending $6 million AND YOU GOT RID OF COVID FOR AN EXTRA MILLION BUCKS!!! Even if we test 100 people for each positive, because people lie and say they were exposed just to get the $20, you are still only looking at another $7–8 million to GET RID OF COVID.

WHY WILL THIS WORK?
The reason why we only need 50% of China’s contact tracing instead of 100% is because the virus is not as bad as we thought it was. China’s contact tracing system is overkill for COVID. It is very, very transmissible in a naïve population — in NYC in February, the R was 3.5. But, the R quickly, quickly drops when you institute things like no large indoor crowds. This may have to do with something called K. The virus might need large crowds to really spread because most people don’t spread it all and only a few people spread it a whole lot. So, once we eliminated large crowds, our “natural” R is around 1.5, as we see in Florida right now. That’s why even a half-effective contact tracing effort will get the R down below 1.
In short, we got incredibly lucky. This could have been much much worse. If it had been much worse, the worst case scenarios that all the models predicted in March would have come true and the only way out would have been full, China-style lockdowns. But we got lucky. Because of the low K, the virus is MUCH more responsive to distancing measures than even the experts thought. Now its up to us to take advantage of that luck.

WHAT WOULD THE FUTURE BE?
Once we get cases to zero in a community, we can resume normal life. I mean completely normal. No masks, no distancing, nothing. Because cases are at zero.
The only difference will be that everyone that gets sick with any kind of COVID like symptoms would have to get tested and isolate immediately. This is because people will come from other places and outbreaks will resume. However, even with an R of 3, there will be plenty of time to catch outbreaks before they get out of control. Say an outbreak starts in a community with 5 cases. Even after 14 days (7 doublings), you are only at ~650 cases. If you catch it by then, you eliminate large gatherings indoors and do contact tracing for a couple weeks, until it disappears. So you have basically normal life, with occasional COVID emergencies that disrupt life a little, but hopefully they are few and far between.
All it would take is a massive investment in testing and an understanding of what the priority is in contact tracing.

WHAT ISN’T HAPPENING RIGHT NOW?
Four things:

One, There is no sense in this country that the goal of our COVID policy is to eliminate COVID from the country. Half the country thinks that everyone is going to get infected anyway and we were just trying to make sure that health care systems are not overwhelmed. The other half things that we just have to do our best to live under severe restrictions until a vaccine comes. There needs to be a clear message that COVID can be defeated. Once we defeat COVID, we can live close to normal lives until the vaccine comes.

Two, we have not invested enough in testing. In places where COVID testing spikes, people are waiting for hours to get a test. For this to work, it needs to take people 30–45 minutes to get a test. They need to get the results within 12–24 hours. This is not impossible — it will take a massive national investment but it’s possible.
Three, we are not messaging contact tracing properly. The airwaves are not flooded with the one-track message that the thing that you can do to stop the virus is not “wash your hands” or “wear a mask” (even though wearing a mask helps a lot and washing hands might help a little), but go get tested if you have any symptoms or if you have been in contact with anyone who tested positive. Bars need to post signs and put on social media that people who were in the bar at 8:30–10 PM last night were exposed and should go get tested. And we NEED to add a small financial incentive, so people give themselves permission to go get tested.

Think about this: Right now, people worry that they will have to pay to get tested for COVID. That’s crazy. We should be PAYING people to get tested, because testing is the only way to actually KILL COVID.

Four, we need to tell people that getting tested means that you are overwhelmingly likely to get a negative and if you do YOU DON’T HAVE TO QUARANTINE. Remember, even if someone gets a false negative, that’s not the end of the world, because we don’t need to stop every infection, only about half of the infections, to get rid of COVID fairly quickly.

This plan can be tried even in one city. If, for example, the city of New Orleans could find the money to fund the sweeteners for testing and ramp up their testing to handle this volume, they could be rid of COVID in six weeks. It wouldn’t depend on anyone else doing it with us. We can do it by ourselves. And, once we get rid of COVID, we just need to keep pushing testing testing testing for anyone with symptoms and for anyone that was exposed, and we can keep it under control.

We don’t have to lose to COVID — we can still win!