April 16, 2020: The Five Original (Competing?) Imperatives, a Mid-Course (?) Review -

This whole week, I’ve been wanting to circle back to the original imperatives, because I feel as if they are starting to blend together a bit, and also because even if they are distinct, it feels as if they aren’t really competing quite so much as they were.

1. We need herd immunity
2. We need to flatten the curve
3. We need to protect the vulnerable
4. We need to keep the (global, national, and local) economy afloat
5. We need tools (and a bunch of stuff we'll call "tools" so we can have five categories)

Just for fun, let’s take #3, protecting the vulnerable.  Way back when I got sick, it looked as if “the vulnerable” were people over 60, or over 70, or maybe the homeless who had to live squished into shelters or be terribly ill on the streets.

But then quickly it became clear that “the vulnerable” were going to be frontline health care workers, and EMTs without health insurance (oh, god), and everybody who lost their job (now in the tens of millions), and the people whose  businesses were in danger of going under.

And then “protecting the vulnerable” (3) started to look a lot like (2) flattening the curve (stay home, don’t go visit Grandma and DO try to talk her out of going out and KILLING THE WHOLE WEE TOON, like Claire’s mam in Scotland, and also, don’t circulate and make more people sick and cause your healthcare-worker friends and relations to live in places called “Camp COVID” at the hospital for a month). And “protecting the vulnerable” (3) also started to look a lot like (4) keeping the economy afloat ( buy something from a local business or send money to the Food Bank or donate to the fund that is trying to support folks who make a living in the performing arts).

“The vulnerable” turned out to be a lot of us, not really surprising, given the human condition.  Then “the vulnerable” turned out to include the Post Office.

And #5, we need tools, began to be visible everywhere. The most basic tool is a valid number, and we have no valid numbers, even now. We have tiny, non-random samples. (300-some pregnant women at one hospital, all tested, looks like of those who tested positive, 81% were asymptomatic, can we generalize from that tiny study to believe that if we actually tested everybody, 80% of those who tested positive would be asymptomatic? Numbers out of China and France and one Italian town where they DID test everybody suggest the number asymptomatic might be 50%, or 60% or indeed that 80%.)

And we have terribly non-random big numbers – oh, look, about 80,000 samples sent to one testing facility have not yet been looked at, but hey, that’s down from a backlog of 150,000. And those are just people who were sick enough to get tested! Oh, look, we are twelve days behind reporting deaths in one major city, and if people weren’t tested before they died, they won’t be tested after, so THOSE deaths are not going to be ascribed to COVID….

And #1, the herd immunity one, was always tied to #5, we need tools, from the beginning. We need to know who IS immune, please, and a test is a tool! We need a vaccine, also a tool!  (I really do grasp the imperative for herd immunity, but it often seems to me that the herd immunity purists don’t credit my argument that when someone DIES, that person is no longer a member of the herd. The herd is SMALLER, true, but not more immune.)

As for the vaccine, which is (I fervently hope) a far more convenient and less risky way to gain immunity than having the darn disease, some of the herd immunity purists say We Can’t Wait however long it will take to get the vaccine! I think these folks are suffering from an excluded middle. If we had the tool to test who is immune and let them go about their business, and to test who is ill and to quarantine them and to trace their contacts (but we don’t), we could ride this out until the vaccine comes along. 

It’s not as if the choices are a) EXPOSE EVERBODY ALL AT ONCE (and let deaths skyrocket and hospitals go down under the burden); or, b) STAY IN A CAVE FOR OVER A YEAR, awaiting the vaccine.  Really. There are some middle ways. For instance another tool: mitigating treatments. What if we came up with a way to keep the disease from going to its absolutely worst stages? What if it we had some effective treatments that were enough to keep most people from having to go to the hospital? Health care system doesn’t get torqued beyond belief, people ride out the disease but don’t die, herd immunity builds up. There are a few zillion clinical trials going on about treatments, as you will recall from that nice post with the map and the red circles, not long ago.

Besides - and I’m sure you have been hearing these news stories too - it may not exactly be something we CAN control, the herd immunity thing. Tonight I heard some lovely virology types on the radio saying: To be honest, we don’t know much about what “immunity” means with this one yet.  If it’s like herpes, you get it, and you have it for the rest of your life, and you just keep an eye out for bad flare-ups. If it’s like dengue fever, you get much sicker the second time you are exposed than the first time, in fact, the second time often kills you. 

If it’s like most viruses, you are immune for a while, and if it’s like some viruses, you are immune for good. For some viruses, after a little exposure, you get a milder case of the disease, but you are immune anyway. And for some viruses, if you get a prolonged exposure, you get a worse case of the disease, but should you survive, you, too are immune! COVID-19 seems to be like that, but we don’t know yet if a mild case is just as immunizing as a terrible one. 

Maybe it’s like typhoid! Some people die, while other people get well and are immune, BUT once in a while, there’s somebody like our old pal Typhoid Mary, who ran around asymptomatically shedding virus for the rest of her life, working for various families, getting them all sick, getting jailed, getting out of jail, taking a job working for another family, getting THEM all sick ....

Also, “herd immunity” levels vary by virus. Somebody said the other day that for the less transmissible ones, as little as 60-65% of the herd needs to be immune for the herd to be pretty much protected. A person here and there still gets sick, from time to time, but no massive outbreaks occur. For the most transmissible, it’s about 95%. We don’t know what the percentage for this one is.

It seemed at first as if the herd immunity purists and the flatten-the-curve purists were at loggerheads, but I think that is easing. They curve-flatteners weren’t saying we must never expose anyone (or even that that was an option), just that we need to keep from blowing out the system. And most of the time, the herd-immunity types aren’t saying Everybody Should Just Get It Over With Today - Time’s A-Wasting, If You Die, You Die!

I even think the 4-purists are coming around a bit, realizing that the economy won’t magically LEAP BACK into full production if people are afraid to go to work, or to the store, or to school, afraid if they DO go, they’ll kill someone’s uncle inadvertantly. Even if we order everything online, somebody has to MAKE and grow the things we are ordering, somewhere.

There has been absolute nonsense spewed by our clueless leader since the beginning, but I’m feeling hopeful  that, at other levels, many people are starting to get it. (Not everybody, I know. I am ignoring a lot of stuff I can’t stomach.) You can’t service one imperative and have the whole mess get fixed. It doesn’t work. They are all intertwined.

Caveat:  All of the “science” cited above could well be wrong, and could all change by tomorrow. That’s how 2020 has been so far. Feel free to correct me! I am not going to stick to any of it if it is wrong. I’m just still mulling the big muddle.