Opinion: Where Things Went Wrong
A legacy piece originally published in August 2021 under the title Big Covid Post #5 as part of my 5 part series on the pandemic.
There are many places one could begin a conversation about where things went wrong in the spring of 2020. Even before the first mutation of the RNA that would ultimately become Covid took place you might blame the withdrawal of America’s leadership and investment in global public health initiatives. You might blame years of growing anti-science rhetoric and declining science literacy in the west or the United States’ decaying public health infrastructure. Or you might blame China’s critical early delays in January 2020. Those and more are all reasonable things to choose. But all of that has been written about already. I wish to contribute something new; I wish to avoid the political quicksand inherent in some of those topics; and I wish to tie this topic in with the principles I discussed over the past 4 posts. What follows is not THE answer to where things went wrong as much as it is a framework in which to perceive ANY answer.
Let’s acknowledge that there are a great many things that could have been done earlier which might have set us on a different course and skip to the spring of 2020. If I were to sum up the reason the world is facing its current predicament as concisely as possible I would say it was a “failure of containment”. We failed to contain the pandemic.
Thank you, Mr. Obvious!
No. Here, I mean something very precise. In particular, I mean by containment the phase of an epidemic where every actual infection and every exposure is known. When that condition of “perfect knowledge” applies, the actual cases can be isolated and the exposures can be quarantined. Believe it or not, this process really works…
It has been successfully applied often in the past few decades wherein local epidemics remained local epidemics because world public health officials (usually led by the US) swept in to aid in containment. When containment is deployed, we do not need to apply broad, nonspecific interventions like lockdowns and social distancing indiscriminately as we did with the “flatten the curve” campaign. Focused application of isolation and quarantine minimizes the social and economic impact of epidemic mitigation since only the actually infected and the actually exposed are made to place their participation in society and the economy briefly into abeyance. For the rest of us, it can be largely business as usual.
As long as the isolation-testing-tracing-quarantine machine hums along according to design, the pandemic is confined to brief local flare-ups; contained because everyone affected is known and promptly sequestered. Social and economic effects remain small.
But when containment fails, there is no way to know where the cases or exposures are. The only available approach is to treat everyone as either infected or exposed. Isolating, physical distancing, closing central gathering locations, masking (here there are important nuances), disinfecting (more nuances); these become our only weapons.
Although in March 2020 it felt new to 90% of mankind (and 99% of Americans who enjoy the privilege of having no experiential memory of epidemics like SARS and ebola), this process was well-known to epidemiologists and public health professionals worldwide. It has its own formalism and has been considered “settled science” for over 30 years, taught in basic introductory coursework. Just as airline passengers don’t argue over the science that makes air travel possible instead trusting that scientists and engineers have “worked it all out”; so too, the mechanics of effective epidemic containment: Settled Science. Epidemiologists and public health professionals have worked it all out.
And they have had decades of field experience. Every year, routinely around the world they employ their craft to contain emerging epidemics. The process works so well, the rest of us get to believe epidemics are rare. Public health done right will always look like overreaction. For epidemiologists, their body of achievement — their Emmy Awards and Oscars, their Olympic medals and platinum records — is the catalogue of all the pandemics that never were. So while it may have felt like it to you last spring, public health leaders weren’t “making it up as they went along”.
So if the process works so well, how did we get here?
Well, the process really does work…but its effective implementation has some prerequisites.
For one thing, containment requires a test that is rapid, accurate, and widely available. As discussed above, it also requires cases to be held to relatively low numbers. The peak generally needs to be kept below 10,000 new cases per day in the U.S. and perhaps 30,000 worldwide (on this number I would defer to a public health expert).
Testing must be rapid (ideally results within hours) so that cases can be identified and interviewed and all of their contacts discovered before memory fades. Delayed test results means that some contacts escape identification, quarantine, and serial testing. False negatives and otherwise inaccurate test results lead directly to a leaky containment by failing to identify some actual cases and subsequently failing to quarantine the exposures destined to become future cases. In the same way, lack of test availability produces a leaky containment as some cases remain untested and unidentified. There are many reasons tests may be scarce. These reasons can be geographical or meteorological. They can be related to problems with manufacturing, supply chain, storage, or distribution. Or they may be military or political in nature.
In the case of the test for Covid in the United States, far from being rapid, accurate, and available, testing took days to run, had a false negative rate that was high and uncertain, and was scarce due to some bad early decisions to centralize the manufacture of tests. This centralization meant that when that central manufacturing process turned out to be faulty, rather than have 100 other manufacturing sites around the country already making tests, we had none. This took months to correct and was not communicated to the American public until much later.
The significance of the testing problem in the US was understood by everyone at the top at a very early stage. And it was a colossal failure. It meant that we had to assume Covid was everywhere and that the only weapons we had in the fight were the blunt instruments of lockdown and distancing along with all of their negative externalities.
Testing problems aside, even with a perfect test, Covid was always going to be a difficult virus to contain. You may remember a curious phrase that Anthony Fauci repeated several times in February and March 2020. He said, “this virus has tremendous capabilities.” He never really elaborated. He was referring to Covid’s large R0, airborne spread, asymptomatic spread, and survivability on nonporous surfaces.
Large R0.
Covid (even before the appearance of delta and omicron) is highly infectious. It spreads quickly and to many people. This means that it has the capacity to quickly overwhelm the finite resource of contact tracing. 10,000 new cases a day is about the limit of what contact tracing in the US can handle. But if you wait until you are already getting 10,000 cases per day before you turn on the contact tracing machine, by that time, those 10,000 cases will have exposed many others. R0 tells us how many of those exposures will go on to be secondarily infected. If R0 is 3 as it was for the original wild type Covid, those 10,000 will inevitably cause another 30,000 infections. So if we need to keep cases below 10,000 for an infection with an R0 of 3, then the contact tracing machine must be fully humming by the time the case count is 10,000/3 or 3,333. The higher R0, the lower the case count must be when containment is engaged.
Airborne spread.
Contagions that by virtue of their small, light particles display airborne spread hang in the air for long periods of time and can penetrate cloth, surgical, and improperly fitted or handled N95 masks. They can also be carried long distances in buildings by riding on air currents caused by the air-handling systems present in these buildings and penetrate many of the filters used by those systems. How does this affect containment? If a virus can hang in the air for 15 minutes and be carried through a building’s ventilation system, contact tracing becomes less effective since the transmitter and transmittee may never have come into direct, simultaneous contact with one another. Rather, the exposure may have taken place across time and space: 15 minutes between when one person coughs in a third floor hallway and another person rides the elevator up to the fifth floor stopping briefly on the third floor to let someone out. Airborne spread also constrains the effectiveness of masking as a mitigation strategy limiting the types of masks that are effective perhaps to only N95 masks which are relatively scarce relative to cloth and surgical masks. Still, in the case of Covid, some types of non-N95 masks have proved very useful due to droplet transmission being a much more important mode of transmission than aerosols, a fact that was not yet known in the spring of 2020.
Asymptomatic spread.
A person infected with Covid is infectious for several days before developing symptoms. And some people never develop symptoms at all. Since people who are not sick do not generally seek out nasal swabs, asymptomatic spread contributes directly to leaky containment by preventing some cases from ever being identified. For those who eventually develop symptoms and are identified later, the delay in identification means there are more secondary exposures, more chance of a forgotten contact, and a larger number of contacts that must be traced, tested, and quarantined. This in turn increases the burden on the finite contact-tracing resource. In the case of Covid this effect might back up the point at which containment needed to be engaged by a further factor of 3 or 4 from 3,333 to around 1000.
Survivability on nonporous surfaces.
Last spring, pretty much every epidemiologist in the world expected fomite transmission to be more of a problem with Covid than it turned out to be. Fomite transmission is the term for when an infection is spread from one person to another indirectly with an inanimate object — or a chain of inanimate objects — in between. It is the type of transmission that occurs across a doorknob, elevator button, or shared computer keyboard. If a virus only survives a few minutes or hours on a surface, fomite transmission is inefficient. But when it remains infectious for days as it does in the case of Covid on plastic, glass, and metal, fomite transmission becomes an untraceable hole in containment. This is especially true if retail points of sale turn out to be robust loci of fomite transmission. We are fortunate that in the case of wild type and alpha Covid it was not. (Note: this was written before delta though it turned out also to be true for delta, and may be true for Omicron. Though it is not guaranteed to be true for any future variant.)
By the time Covid arrived in New York, it had already escaped containment around the world. The testing debacle in the U.S. meant we had no idea where or how much of it there was. Because we couldn’t measure the spread, we also couldn’t nail down the actual R0. Thinking that airborne spread greatly outweighed droplet spread, public health officials believed N95 masks — which were in short supply — to be the only useful form of mask and so did not recommend other forms of masking. Finally, everyone thought fomite transmission was a more significant mode of transmission than it was.
One of the questions epidemiologists ask of any epidemic is, “What will be the peak number of simultaneously-infected individuals?” This number it turns out is heavily dependent on R0. In the case of Covid, coupled with an inability to precisely nail down the R0, that number looked to be astronomical. In fact, it was more than half of the US population. Infected. Simultaneously!
If such a scenario had come to pass it would have been devastating for our healthcare system and probably society as a whole. Remember, at the time we were intubating people based on criteria established for other illnesses. It would be a couple of months before we learned that somehow people infected with Covid could survive for a long time with oxygen levels so low we used to consider them incompatible with life (they still are when seen in disease processes other than Covid). Thus was borne “Flatten the curve”. It was a marketing campaign — not a scientific or mathematical one — conceived to protect the healthcare system from total collapse. Even I thought it was rather clever marketing at the time.
We were told that we needed to distance and close schools, entertainment venues, eating establishments, and houses of worship. And for the most part we did. And the curve was flattened. But then, like the aquarium fish in their bags floating in Sydney harbor at the end of Finding Nemo, we looked around and said, “Now what?”
No one had a good answer. “We did it!” we cheered as we asked, “Are we done now, can we go to work and school and restaurants and concerts and baseball games again?” The curve looked pretty flat so we expected the answer to be, “Yes.”
Instead, we were told:
“Hang on!” and “It depends,” and “We’ll have to see how it goes,” and “We’ll let you know when it’s safe to let up,”. . .
. . .“Oh! And also, we think masks would be a good idea after all.”
Wait, WHAT?!?
At best this left some people confused. It made others angry. And it was too easy for politicians to spin into a narrative that the restrictions were about control and had been all along. Given the political climate in this country at the time it was a tenacious narrative.
The “now what?” no one ever told us we were waiting for was in fact containment. In retrospect, “Flatten the curve” was a bad marketing campaign. The marketing campaign should have been, “Contain the pandemic.” Before you admonish me about the pellucid quality of hindsight let me say that the wrongness of the “Flatten the curve” campaign should have been clear to its architects.
Why? Because “Flatten the curve” implies that the endpoint is the flatness of the curve. But such was never the case. The endpoint was containment of the pandemic and containment only occurs when the prerequisites described above are met. Namely, the existence of a widely available, rapid, and accurate test and fewer than 1000 daily new cases in the US. When people started rebelling against lockdowns and masking we were about 2 months away from having a test that fit the bill. Of course no one had any way of knowing that at the time. But imagine the campaign had been “Contain the pandemic.” In that case, the messaging would have gone something like this.
“We need to contain this pandemic. To do so requires that we get case numbers down under 1,000 per day and keep them there until we have a rapid, accurate, and widely available test. Right now, the test we have is faulty but scientists are working on that. It is unclear how long that will take but it is likely to be at least a few months. Perhaps longer. Regular progress reports on the development of the new test as well as daily new case numbers will be given regularly.”
Such a message clearly communicates how the lockdown ends by accurately enumerating the target conditions for relaxation of restrictions without setting a date.
We know now, that had we done it this way, the containment conditions would have been present most likely in late August of 2020. The pandemic would have been contained and lockdown would have been lifted probably in September near the start of the school year and well before the holiday season. All cases and exposures would be known, isolated, and quarantined. At any given point in time after that, a few hundred thousand people would have been isolated or quarantined but the other 330 million of us would be going on about our lives. Sure, there would have been periodic local flare ups that would have required more severe intervention on a small scale, and most of us would have found ourselves in quarantine at some point, but that is why it is called containment not elimination.
There is no way to know how things would have unfolded had any particular decision been made or not been made. But whether you think the real moment of failure occurred long before Covid evolved, soon after it evolved, or sometime around when it was exploding in Italy, Spain, or New York, it was a failure of containment that got us where we are now.
Coming Attractions and More
Thank you for reading to the end. If you enjoyed this article, please follow me to be notified of upcoming articles on Covid and other topics. One upcoming piece under the working title “The Storm is Always Perfect” is about how the “new normal” is more than just accepting that covid will always circulate. It is recognizing that pandemics change the world. Systems of government, economic doctrines, the world balance of power are all affected by pandemics. “Capitalism, democracy, and even [REDACTED] are not safe from this or any future pandemic.” The way we interact with each other, educate our children, conduct business and politics, build our homes and workplaces and cities will all be forever altered by covid.
In 2 other completed pieces, Covid: Endgame and The Equation That Ends Pandemics, I discuss the path to endemicity. Getting there in a practical way really does require another lockdown as many countries other than the US are already doing. But we must do it right this time—a real lockdown, not the free-love “Flapper Party” that was the lockdown of spring 2020.
Another upcoming piece called Froth Me! Beer Whore (already available on my FaceBook page) is about celebration and only loosely connected to the pandemic as it looks forward and back to the times we celebrate.