Everything you know is wrong VII: Coronavirus edition

Watching the medical system, governments, and the public come to terms with the coronavirus has been fascinating. It calls to mind the old joke about why they call it “the practice of medicine”: because they haven’t perfected it yet! While viruses are old hat, each behaves differently, so what worked last pandemic may not work this time. The treatment must match the disease, which only becomes clear over time. Meanwhile, it spreads, and sickens, and kills.

Governments face many dilemmas: respond quickly and risk being considered panicky, wait and be charged with neglect. Mandate behavior and you’re a totalitarian, suggest and you’re weak. Act early and the public will weary of your measures, bide your time and the media will roll out a list of casualties.

The public (and the media) bears some responsibility, too. We want clarity when clarity is not possible. Our demands for scientific certainty are answered by Professor Heisenberg, who determined there are areas with fundamental limits about what we can know for sure. Anybody who has faced a serious diagnosis from a doctor across the table knows the routine: they only suggest courses of treatment, not rules. The public writ large got to experience–all at the same time–what only an unlucky few do everyday.

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In that spirit, what’s been wrong about coronavirus? Even though it’s still early, a few obvious “truths” have met their demise:

• Masks, especially homemade or surgical ones, do no good against this virus. Early mask adoption is one of the few consistent characteristics of countries which have experienced a less severe outbreak. Some blame governments for spreading the “useless mask” error, but the CDC message was more nuanced: N95 masks work, but IF the virus spreads mostly via aerosol particles, it will pass through other masks. Researchers now believe that transmission is primarily via droplets (not aerosol), so governments began to recommend or mandate masks. However, aerosol transmission is a possibility, so the government can’t say “wear a mask and you’ll be ok” because that is not always the case. So the utility of masks was really a function of understanding the disease. Sadly, some still believe masks are not helpful at all.
• Lockdowns are a solution, not just a measure to buy time and “flatten the curve.” A lockdown does work. If everybody on the planet locked themselves in their houses for fourteen days (the apparent incubation period), the virus would be at least temporarily arrested. But most people can’t do that. Governments sold lockdowns as a means to slow the spread of the disease, avoid overrun hospitals (i.e., flatten the curve ) and buy time for therapies and vaccines. But no country can extend a lockdown for months, let alone a year (when a vaccine might be ready). Which leads to a related falsehood:
• Reopening the economy puts money ahead of lives. This is a particularly nasty charge, that if a nation reopens it does so heedless of the possible deaths which would ensue. More importantly, it is wrong. There is death on both sides of the ledger: Covid19 deaths versus heart attacks missed, cancer undiagnosed, deaths of despair accelerated and so on. Some suggest that the immediacy of coronavirus death trumps the counter argument, but that is also wrong. The World Food Program, the UN organization responsible for fighting world hunger, has noted that the breakdown in the global economy will place another 130 million people (total 265 million) worldwide in danger of starving by the end of this year.
• Massive testing is a prerequisite for successful reopening of any national economy. The media especially likes this one. Here is a simple fact: no country has attempted to do massive testing, and the countries deemed by the media as “successful” haven’t even tried to do massive testing. I am not quibbling about the word “massive” here. Some suggest the US, which currently does over 350k tests a day (and is the world’s leader in that statistic), needs to do three million tests a day, indicating a massive shortfall. South Korea, the paragon for testing, has never done more than 14k tests a day. The key? Early, targeted testing. As each new case developed, Korea traced and tested everybody exposed (not everybody who wants a test), requiring fewer overall tests and giving better, immediate feedback. This is a model which can be implemented at any time in the pandemic timeline, but works best earlier. Oh (pun intended), and South Korea never did a lockdown.
• Herd immunity is a long term solution. Herd immunity is the concept that once enough people have been exposed and are now immune, the virus will die out for lack of new people to infect. It is only a solution in the same way that waiting for the summer to dry things out was a solution to Hurricane Katrina for New Orleans. No country is trying to achieve herd immunity: some erroneously suggest that Sweden is doing so, but instead they are simply avoiding closing the economy while protecting the most vulnerable populations (voluntarily locking down the vulnerable, not everybody). The success of their approach won’t be known until the pandemic ends, we add up the death and economic tolls, and compare results.

Perhaps the most interesting “wrong” thing I uncovered about coronavirus is how it spreads. Because it spread so quickly, epidemiologists initially assumed it was primarily an aerosol particle transmission, like the flu or measles. Most highly contagious diseases are airborne. However, as more data came in, it was apparent that while some airborne spread was happening, cases of direct contact with droplets were more the norm, and that the average infected patient infected no one at all!

As the medical field gathers more data, they have found some patients produce and expel far more virus than others, and that the viral load any patient produces varies over time. Some asymptomatic patients produce almost none. There are now data from several natural experiments: the infection aboard closed cruise ships, the isolated Italian town of Vo’, several quarantined nursing homes in the States, the choir incident in the state of Washington. There is also the established story of the unusual spread of infection, high initially in China. Then to Europe and the US coasts, but in different ways, and at different rates.

The more that epidemiologists study it, they are identifying superspreader events as a key to transmission. What are superspreader events? Indoor meetings of closely-gathered people doing things like singing, talking loudly, and interacting. Introduce a high-viral load infected person to these events, and a mass spread occurs. For example, at the two-hour choir practice in Washington, fifty-three of sixty-one choir members got sick!

The story of how the virus spreads is not so much “wrong” but simply how we learn what the truth about the virus is. And what it means. Perhaps outdoor baseball with fans in the bright sun is ok, but indoor basketball is a no-go. An evening with friends at a quiet bar, maybe; a mosh pit at the concert and afterparty karaoke, hmmmm, no. Yes to church services with communion in hand, social distancing, music but no singing; nope to loud choirs, sing alongs, common cup, hand-holding & hugs. Dining al fresco at spaced tables under the stars: si! Eating at a crowded, loud food court in the Mall: no.

And this may all change, too, as we learn more. It’s not a conspiracy, nor is it evidence of lying or incompetence. It’s called science, which proceeds by trial-and-error. Don’t forget the error part. It’s especially important.