COVID-19, Health, Top Stories

Risk, Uncertainty, and COVID-19 Strategies

Former World Bank President Jim Yong Kim recently argued that “[n]o one in the field of infectious disease or public health can say they are surprised about a pandemic.” And yet, the COVID-19 outbreak did take most policymakers very much by surprise. From their perspective, the situation was still one characterized by the kind of radical uncertainty highlighted by economists such as Frank Knight and George Shackle: Policymakers were simply unable to assess the possible consequences of action and inaction, and this made informed cost-benefit analyses of alternative (probabilistically assessed) outcomes impossible. One thing was, however, clear: The consequences of a runaway pandemic could be disastrous.

In such a situation, the precautionary principle tends to apply. As a prominent member of the Danish parliament told us in mid-March: “This is a natural disaster in slow motion. We basically know nothing. The only rational thing to do is to shut down entirely.” That was six weeks ago. At the time of writing, we are already in a very different situation. Now that many more data points are available, sophisticated cost-benefit analyses are emerging, and the curves depicting those who are hospitalized, in intensive care, or dying are flattening or even dropping in many places. We are moving from a situation of radical uncertainty to one that is in many respects more like a risky situation—one in which we can be fairly confident of what the likely outcomes of our actions and the associated costs and benefits will be.

This shift has occurred as a result of observing new developments and analyzing the data those developments produce—testing and re-testing infected individuals, recording and comparing hospital data across countries and regions, and so on. This gradual transformation of uncertainty into risk (and finally into certainty) is not a process that follows any predetermined path. Rather, it is a search for the right responses partly shaped by existing institutions and policies. We now know enough to identify some important challenges to this process, including some pitfalls, familiar from the literature on cognitive biases.

The dramatic early pictures from Lombardy, in particular, including footage of military trucks transporting corpses out of Bergamo, received extensive coverage on mainstream as well as social media and were widely cited by policy makers. So were the alarming outcomes predicted by the widely cited Imperial College simulation study (based on still undisclosed code written to simulate a flu epidemic 13 years ago). Focusing on these early reference points to the exclusion of other important considerations arguably sent information gathering down suboptimal paths, a problem compounded by political and institutional factors, and by poor risk literacy among decision makers as well as the public. This has hampered the sober assessment of costs and benefits of exit strategies from the current measures.

In what follows, we examine ways of taming the uncertainties associated with the crisis. We identify likely mistakes in the global search for responses, what we can learn from them, and how we can move forward to create viable and publicly accepted exit strategies.

Unknown unknowns, known unknowns, and known enough knowns

At a press briefing in 2002 as America prepared for the invasion of Iraq, US defense secretary Donald Rumsfeld famously drew a distinction between “known unknowns” and “unknown unknowns.” Rumsfeld was ridiculed in some quarters, but this insight into the nature of risk assessment (which was not original to him) is profound, and may be applied to our current situation. COVID-19 was initially an unknown unknown that quickly became a known unknown once the new disease and the novel coronavirus that caused it were identified.

As the death toll climbed rapidly in Italy, the possibility that similar catastrophes were about to unfold in other cities led governments to assume the worst. But the nature of their responses in this phase were very different. The Taiwanese authorities acted immediately, calling a crisis meeting at government level in December 2019, the same day the authorities learned of an emerging epidemic in Wuhan, China. By contrast, the Danish health authorities were still reluctant to issue warnings against going skiing in the Italian Alps by late February 2020. Retrieval biases might have played an important role in the response patterns: Taiwan had been hit by the SARS epidemic in 2003 (another contagious respiratory illness which also originated in China), while Denmark’s only recent experiences with epidemics were its annual bouts of influenza.

In any case, when the potential threat of the pandemic became clear, responses necessarily had to be made in circumstances of deep uncertainty—most of the costs and benefits of response measures could not be meaningfully assessed, because so much of the information required to do so was still missing or unclear. The early dynamics of the crisis were unpredictable because almost nothing was known about the epidemiological parameters of the novel virus, the possible role of super-spreaders, or the nature of contact patterns. The complex repercussions for the economy were also unknown and unknowable. As a result, optimal response strategies (whether in terms of saving as many life-years as possible or minimizing harm to GNP) could not be devised.

However, once COVID-19 became a known enough known, the knowledge accrued thus far could be employed to stabilize the global economy and political systems, to reduce the death toll, and to mitigate the economic and personal trauma caused by the effective shutdown of large swathes of societies.

Avoiding pitfalls in early crisis policy responses

When faced with a situation like the COVID-19 pandemic, political leaders and their advisors must embark on a rapid process of learning and discovery necessary to inform urgent decision-making. However, this process takes place under the impact of threat responses that are likely to disfigure decision-making in various ways. In the weeks after the dramatic pictures from Lombardy circulated the world, many epidemiological experts offered policymakers worst-case scenarios and proposed far-reaching measures to fight the pandemic. This is understandable—these experts were dealing with an unknown virus, and their responsibility at such times squarely lies in preventing a foreseeable medical disaster.

Less understandable is why policymakers relied exclusively on these experts and rarely formed interdisciplinary teams to think through related global health, economic, political, and social dynamics simultaneously. The response strategy that most countries followed was based on the following heuristic: Listen, almost exclusively, to epidemiological experts, and place great emphasis in decision-making on the scenarios that emerge from pandemic modeling. These tended to recommend shutting down societies in order to meet social distancing requirements intended to arrest the spread of the virus. This initial collective response to the COVID-19 outbreak relied on relatively few experts from a narrow range of disciplines and institutions. These included, notably, the simulation study provided by the response team at Imperial College London and the early fatality rate figures provided by the World Health Organization (WHO).

This approach, however, can be problematic. The Imperial College study has been criticized for focusing primarily on the benefits of the courses of action it examined, at the expense of their corresponding economic and social costs and consequences (which can also be lethal). The WHO, meanwhile, has been criticized for failing to perform in-population studies early on (some of which are now underway) that might have assisted a cost/benefit analysis of measures proposed to combat the virus. Consequently, two mistakes in the global policy response at this stage can now be identified:

  • The early shutdown was used to shore up the capacity of the medical system, planning for the worst, but an opportunity was missed to manage the transition from a known unknown to a known enough known.
  • The political dynamic of the crisis created a spiral of confirmation biases and escalating commitment. Absent was the management of attention needed for policymakers and the wider public to maintain a wider perspective, enabling them to compare the costs and benefits of different courses of action, or at least to work towards making such comparison possible.

The associated risk is that the second stage of the crisis response will now be driven by the pursuit of political advantage taking rather than the search for a response which is of greatest benefit to society.

In the wider public, the rationale behind the extreme shut-down measures (“flattening the curve”) was initially accepted. Indeed, graphs measuring new infections and deaths became important visual instruments for educating citizens in the logic of exponential growth. However, the public was not educated in elementary statistics and the dangers of sampling biases (for example, the fatality rates initially communicated in the media and by the WHO generally overestimated the number of infected people dying, because only the sickest patients were being tested). This effectively prevented them from being empowered to make their own risk assessments.

Image: Jordan Hopkins (Flickr)

While epidemiological experts did try to educate the public and allocated ample time to this, they did not always manage to communicate the seriousness of the situation without slipping into counterproductive alarmism. When case numbers in Germany were still in three digits, the virologist Christian Drosten from Charité Berlin, one of the key advisors of Chancellor Angela Merkel, frightened the public by declaringes wird schlimm werden.” (roughly, “It will be nasty.”) Merkel herself judged it to be the most severe crisis since the Second World War. This kind of language together with the logic of exponential growth of infections and deaths, arguably contributed to a widespread willingness to accept the drastic measures that were necessary in the early days of the pandemic. But it had unintended consequences, too.

First, frightening statements from leaders and health officials may help to impede logical thought which, in turn, can cause conspiracy theories to proliferate. On social media and in the blogosphere, doubts about the existence of COVID-19 circulate, while others link the ongoing public health crisis to the 5G network rollout. Others have taken to accusing Bill Gates of masterminding the pandemic as part of a global vaccine profiteering scheme, or to postulating that the shutdowns represent coordinated action to implement a lasting totalitarian political system. Alternatively, the public commitment to draconian measures may become too strong, causing citizens to resist their relaxation when it becomes safe to do so or tolerate wildly disproportionate enforcement. In Serbia, citizens have been jailed for several years for breaking lockdown rules. In general, the prevailing uncertainty during the lockdown weeks has given rise to many worrying political and moral responses from individuals. Some judge everyone who questions the measures to be selfish or lunatic. Others are losing their trust in democracy.

A more balanced and cooperative approach would be for those who are afraid to allow others to question the measures, and for those who are doubtful to obey to the measures anyway for the time being. A common understanding that we are all adapting to a rapidly developing situation that we need to think through ourselves may prevent many from expecting a political disaster. The question “Where will all this lead?” can, and should, be answered early on. After all, the current crisis is hardly a “black swan” event, and valuable lessons can be drawn from the dynamics of known precedents. Policymakers should be more forthcoming about prevailing uncertainty by replacing apocalyptic predictions with candid admissions that “We don’t know how bad it will be” and circumspect pronouncements such as, “Until time point X when we have data Y we will not know if there is a need for long-term measure Z.”

Taming uncertainties

With the benefit of hindsight, we can point to a number of policy failures (such as the failure to expedite widespread, regular testing to gauge the spread of the pandemic) or worse (the early attempts of Chinese authorities to suppress information relating to the coronavirus). However, decisions in the early days were being made in the dark, and similar epistemic conditions are likely to characterize decision-making situations when the next truly grave crisis occurs. Even though we are still operating in a highly uncertain situation, we have learned enough that a few suggestions for comparing and selecting exit strategies may be offered.

First, it is better to rely on simple rather than computationally sophisticated modeling. Simulation models are valuable when studying epidemics, but they are ill-suited to formulating policies while a pandemic is ongoing. Policymakers, leading experts, and an educated part of the wider population must be able to draw on a “common currency of understanding” from which to derive policy responses—it must be clear under what conditions certain scenarios prevail. Complex simulation models are opaque, but readily comprehensible datasets from testing create a common epistemic currency for anyone conversant in basic statistics. Of course, it will still be necessary to explain how the tests work, how reliable they are, if people who are infected can get reinfected, and so on. But by focusing on in-population random sampling, these points can be resolved in public debate. In sum, we need simple models that enable policymakers and the public to think. We should not outsource thinking to epidemiologists, who may be under pressures that prevent them from seeing the big picture.

Second, given some knowledge of population-wide effects, we can use simple statistical comparisons to check upper and lower bounds of impacts of policies. For instance, once the virus’s infection fatality rate is confirmed, likely projections of total deaths are straightforward to calculate. We can already deduce plausible lower bounds for the economic damage caused by suppression measures by carefully deriving lower bounds of expected unemployment, and by studying the known consequences of shut-downs and social distancing. That unemployed men have significantly higher suicide rates, for instance, is now a very well supported claim. We also know that deaths from alcoholism and/or nicotine addiction are correlated with economic recessions and confinement measures. The problems caused by COVID-19 policy measures are not likely to be very different.

Third, we need to be aware that what we are studying is both simple and complex. Exactly how COVID-19 is transmitted and exactly how it affects the human body are two complex questions that are unlikely to be answered soon. However, it would be a big mistake to say that such obstacles should stop us from simple in-population risk modeling. Current modeling attempts should focus on knowable aggregate effects, not the details of mechanisms. Even if a phenomenon is complex (like the transmission of the common flu), some aggregate properties are stable (like its in-population fatality rate given consistent conditions). By combining statistical knowledge about aggregate effects with counterfactual, hypothetical thinking, we may be able to learn even more. For instance, why has the Swedish experience so far not reflected that of Lombardy or Madrid, even though no tough measures were taken by the Swedish government? Once we have forwarded testable hypotheses in response to questions like these, we can try to support and falsify them.

Fourth, the rhetoric used to justify extreme measures needs to be very carefully chosen. While every policymaker wants to avoid the appearance of complacency or sleepwalking into a public health disaster like the one that befell Lombardy, comparisons with war-zones evoke fearful responses in publics that can run in unpredictable directions and become difficult to control. This in turn undermines the rational reflection that enables individuals to cooperate voluntarily. It is important to realize that, if we do not tame the uncertainties associated with COVID-19, the social, economic, and political risks associated with the countermeasures create unbounded risks. Not enough attention has so far been paid to the fact that institutions like the European Union, the postwar liberal order, and in some places, even democracy itself, are gravely threatened by this crisis.

Conclusions

Taken together, we would like to propose a preliminary heuristic for taming uncertainties and managing the crisis response as unknown knowns become known enough knowns that allow for policy formulation. For addressing known unknown situations with the capacity to cause great suffering and harm, a rough heuristic should include the following elements:

  1. After observing a threat (say, the situation in Lombardy in February and March), take drastic short-term measures. This may mean shutting down social life to buy time in which to take emergency measures. However, this phase should be limited to a very short period of, say, two weeks and must go hand in hand with a fully committed effort to adjust policy responses as more and better data become available, and countries move from situations of radical uncertainty to situations of informed risk.
  2. Just after the initial short period of drastic measures, communicate a preliminary set of questions that need to be answered to tame uncertainty, and communicate prospective dates by which they can hopefully be answered. Be cautious not to create common emotions of panic with inflammatory or alarmist comparisons (like “most severe crisis since the Second World War”); if it remains a known unknown, make comparisons based on a risk comparison, see point 4 below).
  3. Manage the transition from an emergency mode of policymaking to committed contingency planning. In particular, the emergency mode should be discontinued once remaining uncertainties are comparable to other known sources of uncertainty. Of course, COVID-19 could mutate, and/or create unknown harmful effects. But similar uncertainties apply, for instance, to new technologies.
  4. Balance long-term measures designed to mitigate the impact of COVID-19 with the need to address other and related sources of hardship and suffering that those measures may unintentionally exacerbate, such as deaths as consequences of loneliness, untreated other illnesses, unemployment, and so on.

In sum, the current crisis is a reminder that democratic, free societies require individuals who are empowered to form their own deliberate viewpoints, and cooperate to create and protect society and one another. Managing knowledge needed to inform policy responses and individual behavior is an important component of such empowerment. The current crisis has highlighted the risks associated with untamed uncertainty, as well as those associated with under- or overestimating the impact of measures intended to combat COVID-19.

 

Dr. Timo Ehrig is a scientist at the Max Planck Institute for Mathematics in the Sciences in Leipzig. He studies how we can make decisions under radical uncertainty and, in particular, how we can form and revise visions.

Nicolai J Foss is Chaired Professor of Strategy at the Copenhagen Business School. He studies how uncertainty shapes organizational structures and strategies. You can follow him on Twitter @NicolaiFoss.

Photo by Michael Walter on Unsplash.

Comments

  1. This was very good, neither alarmist nor denialist. We need more of this sort of thing in public discussions.

  2. Good piece. Among other ideas, closing down for two weeks to figure out and set up a plan to protect the most vulnerable would’ve made sense. The Canadian government provided a study in mixed messages. We were told that it could be “the big one” we’ve been warned about for years, but the gov’t took none of the actions one would expect if they believed their own words. Our gov’t—including our health authorities—seemed more concerned with the spread of racism, the appearance of solidarity with the WHO, and saving the PRC’s image.

    Anyway, I think a couple of things that contributed to the uncertainty weren’t mentioned. For one, the blind trust in the WHO. In Canada and elsewhere, health authorities took WHO figures and recommendations at face value. But the unreliability of the WHO, especially around China, was a known known—national gov’ts should’ve assumed the WHO was as concerned with saving PRC face as it was with accuracy.

    Second, it was obvious that gov’ts and health officials themselves either had no plan for such a scenario or ignored the plan they had, which caused them to panic and seek guidance from a father figure, the most confident guy in the room. (The exceptions here appear to be Taiwan, Singapore, and, of course, Sweden, which stuck to its own plan and ignored the screeching of the medical hive-mind.) But it wasn’t only gov’ts. Our health officials came off looking particularly foolish. Their go-to lines about the dangers or face masks and the unanimous chant “Borders don’t stop viruses!” were so obviously contrived, paternalistic messages that their only effect was to undermine public confidence in those who uttered them.

  3. Writing from the US where covid-19 has become completely politicized going into the November elections, the author’s plea for is far too little far too late.

    The US has been without an effective representative government since January 2017. It reminds me of the old USSR after 1986.

    Still worse, in the US the electorate lack both a common vocabulary and a common set of values. We have two cultures that cannot understand and really do hate each other. The division here is close to 50-50.

    This viral outbreak has narrowed the political issues going into November to two stark alternatives.

    The option imputed to Trump; re-open the economy and allow some unknown and unknowable number of individuals to die from the virus.

    The option imputed to Biden; save some unknown and unknowable number of individuals by shutting down both the economy and all individual liberties and print money to provide an income to all.

    The arguments that advocate totalitarian methods to eradicate covid-19 remind me of the novel Moby Dick with covid-19 playing the part of the Great White Whale and our experts in epidemiology the part of Captain Ahab. The virus is a force of nature and attempting to hunt it death at the cost of everything is, to my mind, blasphemy. But there is no one here willing to challenge these experts.

    It may be the US will collapse like the USSR did in 2021.

  4. As far as I can tell, this option is not actually what he’s advocating for.

    I am actually very much in favour of reopening the economy slowly and cautiously, now that it looks like we have passed the peak. What I want is a little more local Authority, so that people in rural areas who are less vulnerable to it get to open on a different schedule than suburbanites and than urbanites. I also think that different states need to use different amounts of discretion, as well as different counties within the states. Above all, what I really want is for it to be data-driven.

  5. Dramatic hyperbole. There was no significant change specific to that month except in the minds of a certain subset.

    Europe will collapse before the US does.

  6. The U.S. has been without an informative press for longer than that, but it got much worse after Mr. Trump was elected. When we needed reliable dissemination of information to help us understand, the press was allocating ink to take-down-Trump at any cost. The same could be said about many of our destructive legislators who larded bills with their favorite political candy.

  7. I’m not saying that you should ignore them, what I’m saying is that if you make a decision without paying attention to the data, or let it panic you, it’s not a good idea.

    Balancing data and ethics is tricky, there is no denying it. What I have an issue with is when you decide based on emotional or ethical reasons without consulting the data.

    A couple of things here. One, vaccine does not replace natural immunity, it augments it. Two, we don’t have it yet, which is the problem. Look, if we had the vaccine, there would be no problem, because anyone who got the vaccine would have it boosting their natural immunity to Coronavirus. And that’s the problem, if you’re already immune, or at least have enough antibodies to it that you should be able to resist it, then you should be able to head out and work, as long as you don’t also have the virus. The problem is that if you don’t know that you’ve been exposed, and you wander out and expose other people to your virus, there’s a decently High chance of harming them, especially if they are elderly. And if we don’t know that you’re immune, it’s hard to justify releasing you.

    One of the things that is actually kind of scary about this whole thing is how many people have developed immunity to it. Not that bad, it’s a good thing. The problem is that if this virus had the lethality that was first reported, the death toll would have been extremely high, because it is apparent that we are far more interconnected and able to pass on a virus of this type then we thought we were. Makes you hope the next one is less lethal as well. If we get a more lethal one, we’re going to be way behind the 8-ball, and people are going to be dropping like flies.

  8. The vast majority of people who suffer suffer serious harm or death from COVID-19 are those whose vitamin D level (25OHD) is below 30ng/ml (75 nmol/L). Most people in developed nations who do not supplement with vitamin D3 have levels below or close to 30ng/ml. In winter it is impossible to get enough sunlight to produce much D3 ourselves.

    Inadequate vitamin D, compounded by other nutritional deficiencies and genetic variation leads to a dysregulated immune response in which the initial antiviral innate immune responses are too weak, so the infection is not stopped in the throat, and proceeds to the lungs. Then, the dysregulation continues to cause inadequate antiviral responses and also drives overly-aggressive pro-inflammatory responses. This is true of sepsis, severe influenza and other diseases. The dysregulated pro-inflammatory response to COVID-19 lung infection damages the epithelial cells (inner layer of blood vessels) there, causing both lack of oxygenation and the hypercoagulative state of the blood. This state leads to embolisms (clots) in the lungs, brain, heart, kidneys and liver - so causing temporary or permanent harm and death. This is explained in the Paul Marik Protocol mentioned below.

    It is our collective opinion that the historically high levels of morbidity and mortality from COVID-19 is due to a single factor: the widespread and inappropriate reluctance amongst intensivists to employ anti-inflammatory and anticoagulant treatments, including corticosteroid therapy early in the course of a patient’s hospitalization. It is essential to recognize that it is not the virus that is killing the patient, rather it is the patient’s overactive immune system. The flames of the “cytokine fire” are out of control and need to be extinguished. Providing supportive care (with ventilators that themselves stoke the fire) and waiting for the cytokine fire to burn itself out simply does not work… this approach has FAILED and has led to the death of tens of thousands of patients.

    The systematic failure of critical care systems to adopt corticosteroid therapy resulted from the published recommendations against corticosteroids use by the World Health Organization (WHO) [and other organisations]].

    Furthermore, Vitamin D insufficiency exacerbates the cytokine storm and likely increases the risk of death.

    If everyone took 4000IU vitamin D3 a day, only some tiny fraction of the population would have 25OHD levels below 30ng/ml and this virus would cause little or no harm or death. This is a gram every 27 years. The ex-factory price of pharmeceutical grade D3 is USD$2,500. It is made primarily in China and India. So for 9 cents a year, plus the cost of making 52 weekly or 26 fortnightly capsules, a person can be protected from serious COVID-19 symptoms. Their bone health would be improved and they would be at much lower risk of suffering from sepsis, Alzheimer’s disease, Parkinson’s disease, dementia with Lewy bodies, asthma, IBD, Crohn’s disease, type 2 diabetes and many other chronic diseases which increasingly plague humanity. Likewise, influenza would cause little harm or death.

    A sophisticated cost-benefit analysis would prioritise, above all things, as a matter of extreme urgency, getting everyone vitamin D replete. 100 micrograms a day of prevention is worth thousands of tonnes of hospital cure and lockdowns.

    Please see my comment to the recent story https://quillette.com/2020/05/03/an-icu-doctor-reports-from-the-frontline/ (Quillette Circle: An ICU Doctor Reports From the Frontline) and my pages http://aminotheory.com/cv19/ for links to the research which justifies my statements here.

    Please also see the Protocols form Paul Marik https://www.evms.edu/covid-19/medical_information_resources/ and the Frontline COVID-19
    Critical Care Working Group https://covid19criticalcare.com which shows that IV vitamin C, B1, inflammation reducing corticosteroids and anticoagulative drugs protects many COVID-19 patients from serious harm and almost all from death.

    I am dumbfounded that almost everyone assumes this miserable coronavirus, which causes little or no harm to most people, is a global catastrophe in the making, requiring deadly, unsustainable shutdowns and medical heroics. There will be no vaccine cavalry riding in to save humanity. Ventilators are thought of as mechanical life-preserving angels, but COVID-19 patients generally can be kept off ventilators with the Protocols just mentioned.

    The modern diet and lifestyle involves excessive salt, sugar and fat - and nutritional deficiencies including vitamin D, boron, omega-3 fatty acids and potassium. These deficiencies can only be fixed with supplements. (The UVB which creates D3 in our skin also causes skin damage and cancer.) There is no “balanced” form of the modern diet (omega 3s excepted, if we eat a lot of fish) which provide these nutrients in the quantities we need for our bodies to function properly.

    COVID-19 is a pandemic. The spread of the virus cannot be stopped - only slowed at enormous and unsustainable cost.

    It exposes, sharply, urgently and disastrously one of the most common nutritional deficiencies - vitamin D. Ideally we would all take 4000IU (or more for overweight people) and within a week or so our 25OHD levels would be above 30ng/ml. Then we could end the lockdowns, let the pandemic continue, and get back to normal work and life - since almost no-one would have serious symptoms.

    If this needed to be cone for just single mid-sized country, some special orders from stock in India and China would probably provide sufficient D3, which could be made into capsules locally, within two weeks. However, this needs to happen in all countries. China and India need their D3 for their own people.

    The USA needs a tonne a month for its population to be vitamin D replete.

    In six months we could have enough D3 factories to supply all human needs. Chloresterol from wool fat is UVB irradiated with powerful mercury vapour lamps and the resulting D3 refined to be crystalline pure.

    Boron is readily available as technical grade borax, as used in laundry borax. Despite all the research on boron reducing the ill-effects of low vitamin D, and like vitamin D improving immune system regulation, it is not officially recognised as a nutrient for humans. Its molecular mechanisms of action are yet to be elucidated. Boron has a half-life in the body of less than a day, and is generally not built into tissues, so it is important to take it once or twice a day - while vitamin D has a half life of a month or so. Most people get about 1mg boron a day. More than 20mg a day may lead to problems. To be boron replete, we probably need 6 to 12mg a day.

    The death toll from COVID-19 and the diseases previously mentioned is due to immune system dysregulation: firstly, inadequate direct attacks on pathogens; secondly, overly aggressive pro-inflammatory responses which damages our own cells and cause death in the case of COVID-19, influenza etc. or which drive the chronic disease processes of neurodegeneration, kidney stones, IBD etc.

    Boron is more immediately available for billions of people than vitamin D. 1/20th of a gram of borax a day, dissolved in water, provides 6mg boron. Even with no vitamin D supplements, it is reasonable to expect that boron supplements will increase 25OHD levels in the blood and improve immune system regulation in a way which would save many lives. Boron’s anti-inflammatory actions are somewhat different from those of vitamin D. For instance, 10mg boron a day causes kidney stones to crumble - indicating that boron deficiency drives the particular inflammation processes which build the stones. (M R Naghii et al. Preliminary Evidence Hints at a Protective Role for Boron in Urolithiasis https://sci-hub.tw/10.1089/acm.2011.0865 )

    I am dumbfounded by how most people - including clinicians, health officials and politicians - accept that COVID-19 is so deadly that it constitutes a global crisis.

    Perhaps they have been watching zombie movies and think humans have it coming sooner or later. Maybe we do, but this coronavirus is not our doomsday. It is not a serious concern for well nourished people. Viruses such as a more infectious ebola or anything resembling smallpox would be a global disaster.

    This article reflects the consensus view that lockdowns can be effective, but are entirely unsustainable - so we must relax them within the limits of the hospital capacity to deal with the serious symptoms as the infection rates rise again. The idea is that we will do this until a vaccine arrives (it won’t) or - and no-one wants to admit the cost of this - until most people have had the virus.

    Unless we get everyone vitamin D replete, even when we have all had the virus, it will return, and wreak havoc on the vitamin D deficient.

    If we don’t get most people vitamin D replete soon, then the current 250,000 death rate will be dwarfed by the real crisis to come. The lockdowns are unsustainable and social distancing and testing won’t work well enough to stop the virus spreading at a rate which will strain hospital capacity. Perhaps, without vitamin D, if we keep the infection rate slow enough AND all hospitals adopt the Marik Protocol, the death rates would be minimised.

    However, all these measures are vastly more expensive and harmful than getting 1/10,000 of a gram (4000IU) or so of vitamin D3 per day to each person ASAP. My wife and I take three 50,000IU capsules a month: https://www.biotechpharmacal.com/collections/best-sellers/products/d3-50-50-000-iu-1 , which costs (ex shipping) USD$10.80 per person per year.

  9. The real question every world leader and expert must ask and be asked is how so many vast cities and countries so near to China, and mostly democratic, managed to stop the Coronavirus so early and keep their deaths in several cases below ONE death per million population, HUNDREDS of times less than Western and other countries. The authors never even come close to asking that simple question.

  10. Does this part not satisfy you:

    I don’t think the question is simple, but it looks to me like they brought it up.

  11. The response to COVID19, as with most anything, can be traced back to a combination of politics and administrative capacity.

    In China, politics delayed any response as the CCP will reflexively suppress bad news as much as it can. But when they realized that they could not suppress it any more, they could rely on a vast bureaucracy capable of extreme coercive measures to lock everything down. We’ll see how well they handle the economic costs, they are already engaged in a massive nationalistic campaign to mask them.

    Taiwan was “fortunate” in that they live next to China and had experienced SARS, a much more deadly but much less contagious virus. Living next to China makes them very aware of how China suppresses bad news; the Taiwan authorities made their own determination that this was a serious issue before the mainland authorities admitted to any real problems. And the SARS experience gave them two advantages. First, it gave them the political cover to take serious measures quickly. And second, they had the administrative framework in place to do so. They had plans, equipment, and trained personnel ready to move. It’s not enough to just “lock down”, you have to have the masks, PPE, places to put travelers in quarantine, people to look after them, PPE for those who screen people at the airports, and a thousand other details covered.

    In the West, we had none of that. Our administrative procedures were ad hoc; for example, after banning travel from China, the US allowed its own citizens back in (fair enough), but had no PPE for those screening them at the airports, and no effective method for screening them anyway. And even now we lack PPE or any coherent method for contact tracing.

    The political will to do something quickly settled on the standard democratic response of “save as many lives as possible”. The resulting lock downs are still popular in the West, in the US they are still approved by 70% of the population. But it ignores the economic costs, which can be just a deadly in the longer term (poverty is a strong predictor of early death). We won’t know how bad economic impact will be, and the health problems it will cause, for years.

    Not having experienced SARS, the West had few plans in place. Not having China massive coercive apparatus, the West’s response has been scattered. And people are only now trying to figure out what the economic costs of the ensuing lockdowns will be.

    My personal guess, based on known unknowns, is that we over reacted. The death rate from COVID 19 will not prove to be high enough to justify the economic (and related health) costs. But hopefully it will give us the framework to handle such a pandemic more coherently the next time around, when we encounter a virus with a much higher mortality rate. But, my cynical side suspects that when that happens, memories of our current overreaction will scare politicians from reacting quickly enough.

  12. I know what herd immunity is. I’m a biologist. I was trying to figure out what you were saying about it and what that statement meant, since it was a bit ambiguous.

    Actually, there’s a bit more to it than that. I don’t know how well you know Nuclear Physics, but one of the analogies that works for herd immunity is similar to the control rods in a reactor. Basically, they absorb the free neutrons that would otherwise continue the reaction, and the more control rods you have in, the weaker the nuclear reaction is, and if you keep the control rods in all the way for long enough, you shut down the reactor.

    In the same way, if you have enough people in a population who are immune to a disease, it makes it very hard to pass it on, because anyone who passes it to them is ineffectual, they can’t get it. If you get 93% of the population having some level of immunity to a disease, you stop it cold. One of the best ways in which we use herd immunity is actually vaccinations. If we can use vaccinations to establish a level of herd immunity, it makes it harder and harder for the disease to spread through a population, and thus protect the people in it whose immune systems are weak enough that they might to be killed by the disease. Infants, the elderly, Etc.

    One of the things that we do not currently know is how long an immunity to covid-19 will last. Part of it depends on how we gained the immunity, someone who has had it and fought it off successfully, as long as they were not too debilitated by fighting it off, should have a stronger immunity than someone who got it by vaccination. Still, given the cost of getting infected, it’s generally considered better to get it by vaccination, especially as we can always give you a booster shot. This is why we give booster shots for some diseases, because we need to give your body several chances to create a response and also activate the response a couple times. A more recent response is also going to be easier to reactivate, or as a response for the back in time can go dormant.

    Now, given the first numbers we had, especially the first mortality rate that we had for Coronavirus, the British plan was foolhardy. Too many people would have to die. As it is, one of the things that this has given us time to do is let the disease spread through the population and support the people who needed it. If we can get good antibody titers from people, even if they never had symptoms, and if we can get those antibody titers from enough of the population, we can be fairly confident that reopening will not cause a huge Spike.

    Now, your comment about how long herd immunity will last is a good one, we don’t know how long the immune response to coronavirus will last, and we don’t know how strong it is in terms of preventing reinfection. It may be useful to vaccinate even if you have already had mild symptoms to it, especially if we get another wave in the fall. It may act like a booster shot.

    Plus, one of the things that would be really helpful that a vaccine could do for us that we currently don’t have a good way to do is mimic foreign strains. In other words, supposing that the reason that Italy got hammered is partly because the strain that initially got to them was more lethal. Using some of the Italian strain, some of the Indian strains and Chinese strains and US strains and Australian strains in the vaccine could be very useful for us, because then reopening the economy, and thus letting people travel in, would be less risky.

    The more strains we have at least a weak immunity to, the better off we are in terms of preventing it from passing through the population.

  13. Anybody got anything sensible to say about the theory that the MMR vaccine protects against Covid-19?

    It does seem to match quite a few data points:

    • youth has been thoroughly vaccinated with MMR up to age 57 on average. The age where Covid becomes scary.
    • many soldiers sick on aircraft carriers but no deaths. All soldiers are vaccinated.
    • heavy hit countries have different vaccination schemes
    • most intriguing, women were vaccinated against rubella since the seventies. Basically every woman under 90 that had children is vaccinated. Vaccination against Rubella did not happen for men until mid eighties. This could maybe explain the gender discrepancy in deaths.

    I find thus one of the most interesting way out but I read very little about it.

  14. This is an interesting and thought provoking post. However, I have several objections.

    First, not many had the foresight of someone like Nassim Taleb, for example, who predicted this global shock far before many many others, and who would agree with the authors here that this event was no “black swan”. But as the stunning medical realities set in by early March, an “extreme” response is what was absolutely required. The authors acknowledge this, of course, but seem to give it relatively short shrift. The disease case fatality rate is #dead/# infected, where the denominator was, and remains, an atrocious underestimate as the authors suggest, due to ongoing ridiculous levels of undertesting. However, that alone undersells the reality on the ground of medical, ICU, and ventilator capacity. THe case fatality rate only holds if critical care resources are not overwhelmed, but once they are, excess # dead = (# needing vents) - (# of vents available). It is this that led to Lombardy, and NYC; and it is this that represented the emergency, not merely the disease case fatality rate per se.

    Second, I feel epidemiologists (and scientists) are being somewhat unfairly maligned here. They are not the ones who are crafting policy. OTOH, they understand the science far better than the policy makers (and the public). In fact, the science community generally wanted restrictions applied earlier, faster, and harder, as they could see what was coming. THe policy makers lagged behind due to the perceived political cost. And the fault for that perception, IMO, lies with the constituents themselves. That deficiency, in turn, is a product of the failures of our education system to inculcate people with a basic grasp of math, statistics, and science. I see no signs of that improving any time soon. But insofar as policy makers are hamstrung by the constituents they answer to, it should be noted that an earlier response (in “shutting down” etc) would have likely necessitated a shorter one (as the case doubling time as the curve ascends is played out again on the curve’s downslope). So by delaying a small bit of pain early, it has required a great deal of pain now, and for longer. I wonder if the folks protesting at various capitols realize this, as we look ahead towards a second spike, and likely a third thereafter.

    Third, the authors mimic a general public response as we languish in our ongoing slowdowns - that of bemoaning an known unknown. Apart from isolated pockets of calamity, the dire predictions (Imperial College, etc) have not manifested themselves…yet the response is to almost admonish those predictions as fear-mongering, rather than to realize, or at least acknowledge, that it was the painful interim steps that circumvented that natural course and prevented those dire predictions from becoming reality. There is no reason to believe that any part of any country would have a response curve to the disease in any fashion disparate from Lombardy, or NYC; the only difference is your spot in the timeline, and on the curve, at any given time. THose who ignore the lessons of history are doomed to repeat them, and this lesson would have been only weeks away, for everybody.

    I do agree with the authors that an emergency response should be coupled with at least a concept for an endgame for how to emerge therefrom. However, i disagree that such a concept was lacking all this time. It is patently obvious that, when you enter a “lockdown”, then at some point you would have to emerge from it. But how that emergence looks like, and how the reality may look like on the other side, remains a known unknown and is a moving target. I find that the application of a prescriptive timeline (as the authors did with “2 weeks”) to be unhelpful here, and this can hardly serve as a firm yardstick for any and all pandemics or emergencies. As for inciting panic…the blame again lies with the public ourselves, and to our collective ADHD. If we weren’t so slow, maybe our politicians would’ve been comfortable to act sooner, and the peak would have been lower, and we would’ve been done with this sooner.

  15. We may have exhausted our economic capacity to fund a lockdown this time around, and when the mortality rate settles in under 1%, it’s going to make a lot of people assume that the next pandemic is also being exaggerated.

    That might be a problem if it’s not.

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