Breathing with covid-19
We’re going to have to learn to live with this virus
We are going to have to learn to breathe with covid-19. Let me explain.
Governor Ige’s “stay at home” executive order, a type of economic lockdown policy, was changed in early May to the current “safer at home” order, which allows some non-essential businesses to reopen with social distancing in place, and for parks to be used for exercise but not social gatherings. But most businesses remain closed and our unemployment rate remains the highest in the nation at almost 40%.
[The day this piece went to press the Governor shifted state policy to “act with care” rather than “safer at home,” so we are making progress toward reopening.]
Hawaii has had relatively few cases of covid-19 and is, luckily for us, enjoying one of the very lowest per capita infection rate in the U.S (632 cases in a population of 1.42 million).
Figure 1. Comparing states by covid-19 infection rate per capita as of May 11 (source: www.covidtracking.com).
More important than infection rates, we’ve also had very low hospitalizations and deaths. According to a detailed analysis of each state’s death toll by the New York Times, Hawaii had zero excess deaths from March 15 to April 11. This means that we haven’t had any increase in the overall number of deaths compared to past years. We’ve had a number of additional covid-19 deaths since April 11, but some of these are deaths “with” coronavirus, not necessarily deaths from coronavirus.
The next question we should ask is this: will infection rates start to go up as we start opening up and eventually attempt to “get back to normal”?
We will certainly get some new cases and any goal for maintaining zero cases in an interconnected world is not realistic. The rate of new cases, however, can’t be known ahead of time.
In light of this fundamental uncertainty, policymakers should consider a few important factors in considering when and how to fully reopen. More cautious policymakers — mostly Democratic governors in the U.S., for various reasons — have been urging extension of stay-at-home orders because of the risk of increased outbreaks and potentially overwhelming health care systems if infections spike.
But this set of policies (I’ll call them “lockdown policies” for short) assumes that a vaccine is coming that will make it, eventually, safe to reopen once there is a widely available vaccine. If we know a vaccine is coming relatively soon we can and perhaps should endure the great many negative effects that lockdown policies bring, including infringement of many basic civil liberties, massive unemployment, massive bankruptcies, massive increases in public debt, increases in suicide, overdoses, heart disease, cancer, lung disease, domestic abuse, acute hunger around the world, and many others.
But what if a vaccine isn’t coming any time soon? What if it never comes? What if it’s only partially effective anyway?
Stuart Thompson, writing for the New York Times recently calculated that under “normal” scenarios for vaccine development it could be literally decades before a vaccine is available. Add to that difficulty the fact that we’ve never seen a successful coronavirus vaccine developed before (the common cold is a type of coronavirus, for example, as are the SARS and MERS viruses, none of which have vaccines).
Clearly, there is nothing “normal” about the development of a vaccine at this time. But will a global race to a vaccine significantly speed up the normal development process? Maybe we’ll get lucky and find an effective vaccine earlier than history suggests. But can we literally let our economy and our health rest on the hope of getting lucky?
Figure 2. Timeline for potential coronavirus vaccine (source).
Last, the covid-19 vaccine will surely not be 100% effective anyway. The seasonal flu vaccines developed every year or two for the latest strain of seasonal flu is on average only about 45% effective in preventing serious illness. All viruses mutate, so it’s impossible to develop a universally effective vaccine for such viruses.
The coronavirus pandemic is being caused by an already diversifying number of strains of virus, which means that we’ll need to develop not just one but many new coronavirus vaccines in order to achieve the global protection that vaccines are designed to provide with widespread use.
What are we to do then?
The alternative to lockdown policies is to recognize these difficulties with the vaccine path and to plan accordingly. This means gradually easing our current lockdown and attempting to (cautiously) get back to normal life without waiting for a vaccine to save us. We will, under this scenario, use available antiviral medicines (like remdesivir, which has shown a lot of promise in recent trials) and gradually achieve herd immunity by slowly allowing much of the population to get infected over time, but protecting our most vulnerable. I’ll call these alternative policies “reopening policies.”
This isn’t as bad as it sounds. A number of antibody (seroprevalence) surveys have already found relatively high levels of infection in various U.S. and international populations, with the vast majority of people not even showing symptoms, let alone getting sick, being hospitalized or dying. We are also still early in the global spread of the virus, so it is a certainty that we will see asymptomatic spread increase significantly over time. We just don’t know by how much.
In either scenario — lockdown or reopening — we are certain to see some additional infections in Hawaii. But we are already below seasonal excess deaths (from all causes), so when we are weighing the very serious negative effects of lockdown in Hawaii against the potential for adding more hospitalizations and deaths from relaxing lockdown, it seems clear that the balance of risks favors steadily returning to normalcy while keeping our most vulnerable protected.
In other words, once we recognize that a vaccine is unlikely to save us, we need to learn how to breathe with covid-19 — both literally and metaphorically.
That doesn’t mean being stupid. We need to keep our guard up, particularly for the most vulnerable among us — the elderly, those with hypertension, obesity, diabetes, which are the highest risk factors. But we can and should get back to normal life while still being cautious with our most vulnerable.
With such low infection numbers in Hawaii, we can and are using “contact tracing” policies to identify and isolate new infections before they lead to new outbreaks.
Under any scenario, it will take some time for Hawaii to return to normal — will we ever? — but recognizing that a vaccine may not be on the way anytime soon, and maybe never, will allow us to more seriously consider learning how to live with some risk from the virus in the coming years.
Things do get better. We’ll rebound fully from covid-19 before long. It may take years. But we will bounce back and we will be stronger as a community and a state, learning some important lessons from this global pandemic that will leave us better off than before.