There are two ways Colorado can overcome the coronavirus epidemic and return to normal. The first way is if there is development of a treatment for those infected that renders coronavirus non-lethal. The second way is through herd immunity. That’s it. If neither of these happens, we are not back to normal.
Waiting for a treatment is too unpredictable. We can hope for such a development, but hope is not a strategy.
This leaves us with herd immunity as the only path to return to normal. Herd immunity is achieved when enough people in a population are immune to a disease such that the disease does not have enough available victims to continue spreading and eventually peters out.
Herd immunity against coronavirus will be achieved in one of two ways: through infections or through a combination of infections and vaccinations. Reaching herd immunity through a combination of infections and vaccinations means suppressing new infections until a vaccine is widely available.
To be clear, we will never socially distance coronavirus out of existence, and even if we could somehow eradicate it from Colorado’s 5.8 million citizens, nothing could stop it from reentering as people travel into and out of our state.
How is Governor Polis planning on achieving herd immunity?
The Governor recently released data from his advisors that shows restrictions at various levels, including the current level, lasting until the end of the year. Also, in the midst of stabilizing figures for hospitalizations, new cases and fatalities, the Governor stated in a press release on Wednesday that we remain in the “Urgent” stage, presumably requiring the continuation of the current level of societal restrictions. This indicates that the current levels of restrictions are not producing results that would allow significant relaxation.
Additionally, over the last 10 days Colorado has been finding about 350 new cases per day. If the Governor believes that a pace of 350 new cases per day, which equates to 127,750 new cases per year, is cause to remain under “Urgent” restrictions, then it is clear the Governor is not contemplating Colorado reaching the 3 to 4 million infections needed to attain herd immunity without a vaccine.
The Governor’s actions therefore clearly indicate that he is planning on suppressing infections until a vaccine is widely available in 12 to 24 months (or longer). This means he is likely planning for us to be at some significant level of mitigation and/or lockdown for the next year or two. Yes, you read that correctly. Your elected leader may be planning to keep you under at least partial house arrest until 2022 if he, and he alone, deems it necessary.
Further evidencing that this is the Colorado plan, Polis recently stated, “We want to dispel any notion that we can go back to the way things were,” and the rate of new cases “needs to decline” before any confinement relief will be granted.
Colorado’s plan to combat coronavirus.
The Governor’s plan, which tracks with President Trump’s “Opening Up America Again” guidelines, will likely look something like this: When healthcare officials believe that the extreme measures we are now under have slowed the spread of the virus such that we are significantly under today’s rates and within our healthcare system’s capacity, the Governor will allow us slightly more freedoms than we currently have. Perhaps he will let some businesses reopen under social distancing guidelines. Maybe he will even allow some gatherings so your kid can play soccer or you can visit a neighbor.
Any relaxing of restrictions will be followed by a two to four week period of observation to make sure the changes didn’t result in a spike of new cases. If a spike in new cases appears, the changes will be reversed immediately and we will be herded back into our homes. If there is no spike, we could see another round of relaxation, followed by weeks of observation. This pattern would continue until a vaccine is available. During this period, when new cases pop up, a task force would descend on the infected and try to corral and test every recent contact of the infected person.
We would be living in what last month we would have considered a dystopian future of unprecedented governmental control over all of our movements, shuttered houses of worship (large public gatherings will be banned until further notice), accompanied with the threat of jail time if we get too close to our fellow citizens. Seriously, two months ago if you had written a story about a pair of teenagers who sneak out to a park to hold hands only to be captured by a police SWAT team in Hazmat suits you would be laughed out of a publisher’s office. Today, the story could run on CNN.
This plan would last until 2021 or 2022 when a vaccine becomes widely available. Hopefully. If the vaccine hits some technical or production snags, it could be longer – much longer.
Why would Governor Polis take this route? Questionable advice and lost perspective.
As to the questionable advice, the Governor’s advisors (the “COVID-19 Modeling Group”), recently showed him projections showing that if we did nothing, 80,000 Coloradans would die from coronavirus by the end of the year (see Table 5). This figure is wildly out of touch with what most experts are predicting. For example, President Trump’s lockdown recommendation and much of the world’s reactions were based on a study by Imperial College London predicting the U.S. would see 2.2 million deaths if no mitigation action was taken. Colorado’s share of 2.2 million would be 38,444. Yet the Governor’s advisors tell the Governor that inaction would result in more than twice that number.
Moreover, that 2.2 million number was from a March 16 paper. Since then, there have been numerous studies that indicate coronavirus is less lethal than originally thought, including one by the same team on March 30.
A quick side trip into math will demonstrate how far off the 80,000 number is. The first step is to understand Infection Fatality Rate (IFR). The IFR is the total number of deaths caused by a disease divided by the total people infected by the disease. This is different from the often-used case fatality ratio (CFR) which is the total number of deaths caused by a disease divided by the total people confirmed with the disease. A quick example: in a population of 1,000 people, if 500 people are infected, 50 are diagnosed, and 5 have died, the IFR would be 1% (5 out of 500), the CFR would be 10% (5 out of 50), and the overall population infection rate would be 50% (500 out of 1,000).
The next step is to understand the Reproduction Number (R0) for a disease and how it relates to Herd Immunity. R0 is a measure of how a virus spreads through a population. From a given R0, the infection level necessary to reach herd immunity (HI) can be calculated: HI = 1 − 1/R0. For example, an R0 of 3.5 would mean (1-1/3.5) or about 71% of a population must have immunity to stop a disease from spreading.
The March 16 Imperial College London paper assumed 81% (about 266 million; R0 around 5) of the US population would be infected with coronavirus before the pandemic ended. The 2.2 million works out to an IFR of about 0.83% (IFR = 2.2/266). But since that paper was released, estimates of the IFR have lowered.
The March 30 Imperial College London paper put the IFR at 0.657% for China. A paper by The Centre for Evidence-Based Medicine (CEBM) at the University of Oxford placed the IFR “somewhere between 0.1% and 0.36%.” The CEBM estimates the IFR for Iceland is “somewhere between 0.01% and 0.19%.” More recently, a German study that included testing for antibodies of a general population revealed an IFR of about 0.37%.
Now here’s the reason for all of the math. If Colorado did nothing to slow the spread and we experience the current best estimate of an IFR of 0.36% and use the COVID-19 Modeling Group’s estimated R0 of 3.5, we would expect to see around 14,800 deaths from coronavirus. The 3.5 R0 indicates herd immunity is reached at 4.1 million infections in Colorado and 0.36% times 4.1 million is about 14,800.
It is still a terrible number, but a far cry from the 80,000 being placed in front of our Governor. The decisions he makes may be wildly different if he believes 14,800 may die instead of 80,000.
Of note, the 14,800 fatalities would be if we did nothing. If we do anything beyond nothing, such as non-economy destroying measures like wearing masks and practicing better hygiene, the total would be lower. Moreover, if the IFR turns out to be lower, the fatality total would also be lower. This often happens in epidemics: initial IFR estimates tend to be higher than actual final values.
So how did the Governor’s advisors get to 80,000? What assumptions were made that they saw a scenario far worse than the rest of the world? We don’t know. As it seems that the Governor is considering restricting the liberties of almost six million Coloradans, he should at least make public all of the data and models he is using.
In the above analysis, I use data from world renowned experts and institutions and lay bare the underlying calculations and assumptions. The experts that the Governor is relying on should do the same such that the public, including you, me and credentialed authorities, can accurately judge the merits of claims made. In other words, challenge the message, not the messenger.
As to the Governor losing perspective, he and his advisors seem to be of the mindset that coronavirus deaths are a special class of fatality that must be combatted using almost any tool available. But coronavirus fatalities aren’t special; they are like any other type of fatality and should be approached as such.
For any type of fatality, we make an often unspoken calculation: we weigh the cost of avoiding deaths with the pain of the deaths themselves. For example, Colorado likely experienced over a thousand deaths during the 2017-2018 flu season (the CDC estimates 61,099 deaths that season and Colorado’s share would have been about 1,068) and there was zero consideration of a statewide lockdown or forced social distancing. So we can use this as a baseline: Colorado will not issue any mandates to avoid 1,000 flu fatalities.
Yet Colorado is right now actively suppressing coronavirus fatalities to well below what we experienced in 2017-2018. As of this writing, a widely cited model developed by The Institute for Health Metrics and Evaluation (IHME) out of the University of Washington is projecting that Colorado’s present actions will lead to 456 total deaths by August 4, 2020.
To put that in perspective, we are in lockdown and people are told to shelter in place and not visit other households, businesses are closed, jobs are lost, schools are shuttered, kids and adults are being deprived of their social lives, and there are no little league games in the state, all so that we can suppress coronavirus fatalities to a level far below which, just two months ago, we would have ignored. This fact alone reveals the utter lack of perspective of the Governor and should lead to the immediate relaxation of the current measures.
Why the Governor’s approach is wrong.
There are many problems with the strategy of socially suppressing the spread of coronavirus until a vaccine is found.
First, if vaccine is not forthcoming the lockdown could go on indefinitely. Some experts are saying a vaccine may be two years away. But what if there is a technical or manufacturing delay and an effective vaccine is not available for three years? Or four years? We are contemplating significantly reducing the quality of life of almost every single Coloradan for an undetermined amount of time.
Second, we may end up with herd immunity anyway. If the lockdown doesn’t stop the spread of coronavirus as much as hoped, we could still see the 14,800 deaths (or a large portion of them), we would have just spread them out over years. The loss of life would be about the same, but the economic and psychological toll from prolonged lockdown would be tremendous.
A prolonged lockdown could be ineffective for many reasons. For example, it may just not be effective enough tool to stop the spread of the virus. Or people may suffer lockdown fatigue and start to mingle with each other at levels that allow the spread of coronavirus to continue. One could imagine clandestine birthday parties or a secret game of basketball. Civil unrest, which may be just beginning in parts of the country, could also lead to an ineffective and/or unenforceable lockdown. In all of these scenarios, if the lockdown ends due to people not willing to go along with the orders, the time in lockdown would have been in vane and the economic hardship would have been suffered for no benefit.
Third, the economic ruin will be on a scale unmatched by anything we have ever seen in our lifetime. The International Monetary Fund is predicting this year will see the worst economic crisis since the Great Depression, and it will be entirely self-inflicted by conscious choice. One wonders if people who remember the Great Depression were still around, what their choice of action would be.
Fourth, the Governor is supposed to represent the people of the state. Has he considered how the people want to handle the coronavirus pandemic? Has there been a vote, or even a poll? Has he polled people over 80 and asked if they would like the entire economy of Colorado tanked for a year or two to possibly lessen their chance of contracting coronavirus? Maybe they would say they accept that risk. Who knows, we haven’t asked. If we do stay in extended lockdown, does the Governor actually believe it will be what the people want a month from now? How about six months or a year?
Fifth, we need to seriously consider what would happen to many of the people we are trying to shield from coronavirus during an extended lockdown. What would be their quality of life as we sequester them from their families and the rest of society? Around half of the likely victims of coronavirus would be people over 80 years old with an underlying health condition (see this New York City data summary). During a yearlong isolation, how many of the group would be among the roughly 50,000 fatalities per year that Colorado normally experiences? Before judging this as dispassionate, remember that we all collectively did nothing two years ago when over 1,000 Coloradans died from flu.
These five factors all point to a change in strategy from hunker down and wait for a vaccine to a managed plan to achieve herd immunity through infection. This may sound radical, but it is a reasonable alternative. It is currently being enacted in Sweden and has been advocated by many experts including Harvard epidemiologists.
What we should be doing.
Waiting for a vaccine or treatment to save us from this epidemic is too unpredictable and likely impossible and as such should not be pursued. This leaves us with herd immunity through infection as the only viable strategy.
This strategy was what we were told in the beginning; it was “slow the spread” to “flatten the curve,” meaning we would allow the virus to take its course, but at a pace such that no one would go untreated due to lack of healthcare system capacity. We should stick with this strategy and, since Colorado has stabilized, immediately begin lifting the restrictions on the civil liberties of Coloradans.
The lifting of restrictions should be done quickly. The first step should be lifting of all mandatory business closures, the shelter in place orders, and the social distancing orders. Gathering size limitations could also be eased. However, the Governor and other leaders should urge people to continue social distancing and wearing masks when close proximity to other people is anticipated. But these should be recommendations, not draconian laws with threats of imprisonment.
We should also urge businesses to monitor and restrict the density of their employees and customers and ask that they require everybody to wear masks. We should urge restaurants and bars to shut down bars and only provide table service. State and local governments should engage in widespread education efforts regarding hygiene and safe practices to help slow the spread. The Governor should produce a schedule of anticipated future restriction removals, including easing crowd size limitations.
Make no mistake, this will be bad. It will likely be an order of magnitude worse than any flu season in our recent history, but it won’t be as bad as originally feared. This is nature at its cruelest, offering no easy solutions, but together we can get through it.
Finally, I have made a lot of assumptions about the Governor’s plan for Colorado. I have postulated that he intends to try to severely suppress infections all the way until a vaccine is produced. I would like to be wrong about this, but without the Governor clearly announcing his intentions and releasing the data he is using as a basis for his actions, we cannot be sure.
But most of all, Governor Polis needs to begin significantly reopening Colorado now.
Karl Dierenbach is an engineer, attorney and writer living in Centennial