Issue 23: Heterodoxy in a crisis, or, we need a Plan B (Part 2)

Many of the proposed alternatives to test, trace, and isolate are risky. But the question isn't if they are risky, but if they are more risky than betting everything on one plan.

Policy for Pandemics is produced and edited by Andrew Potter and co-edited by Charlotte Reboul and Paisley Sim (bios here). Today’s briefing is by Andrew, and is a followup from Monday’s newsletter which argued that we need to start looking at a Plan B for getting out of the lockdown.  

HETERODOXY IN A CRISIS

Apart from the increasingly unhinged Coronavirus truthers, pretty much everyone agrees that we are caught between two unappealing options: Remain on indefinite lockdown and face economic depression and widespread social malaise. Or try to renormalize economic and social life and face the prospect of the virus spreading unchecked, leading to the deaths of tens of thousands of Canadians. So the widely accepted plan has been to start by “flattening the curve” of transmission to get new cases down to a manageable level. Once that has been achieved, we can start to reopen society, gradually and in carefully calibrated stages. 

To avoid the reopening simply restarting the unchecked chain of transmission of the virus, the next stage of the plan involves mass testing of the population, tracing the contacts of those who test positive, and isolating them. We do this until a vaccine is developed and approved for general use, hopefully sometime in 2021. 

Test, trace, and isolate has become the orthodox plan  for getting back to something approaching normalcy. But as I argued on Monday, there are a number of possible hitches in the strategy. First, it requires ramping up nation-wide testing by at least an order of magnitude. Second, it will likely involve either an army of human contact tracers or the use of privacy-invading digital surveillance technologies, which may generate significant resistance. And third, there is no guarantee that we will develop a workable vaccine within the next 12-18 months.

Compared to the United States and Europe, in Canada there has been very little in the way of out-of-the-box strategic thinking. Since the crisis started, politicians at both the provincial and federal level have been largely content to let policy be dictated by the public health authorities. This was probably a good idea in the early stages of the pandemic, but it is worth keeping in mind two things. First, public health people are trained to worry about one thing and one thing only, and second, when it comes to that one thing they are professionally inclined to be highly risk averse. That is why a lot of the messaging coming out of the public health officials lately seems to have shifted from “flatten the curve in order to spread out the total cases over time” to “crush the curve until we have suppressed the virus.” 

But as the pandemic grinds on, the short-term consideration of “public health” narrowly understood is eventually going to have to be balanced against other interests, other goods, and other risks. That is something the health authorities are not qualified to do, and it will inevitably fall to the politicians to make very difficult judgements under highly uncertain conditions about how to proceed. But If the gamble is on test, trace, and isolate as the only feasible plan, it’s a poor bet. We would be wise to be working on a Plan B. 

What follows are a few of the proposals that go beyond the orthodox plan. Some of these push against the confines of the official box, while others stretch the limits of what is morally permissible and politically feasible. A virtue that they all share as a potential Plan B is that they don’t rely on massive testing and contact tracing to work. 

  1. Alternating Lockdown

The proposal from a group of Israeli researchers is an attempt to deal with one of the more confounding features of the novel coronavirus, namely its long incubation period. So instead of a generalized gradual reopening of society, they propose an alternating lockdown

 in which at every instance, half of the population remains under lock-down while the other half continues to be active, maintaining a routine of weekly succession between activity and lock-down. All symptomatic individuals continue to remain in isolation. Under this regime, if an individual was exposed during their active week, by the time they complete their lock-down they will already begin to exhibit symptoms.

While it is not included in their modelling, the fact that at any given time only half the population would be at work or at school or out and about has the added benefit of making social distancing that much easier. 

  1. Group Testing

This idea comes from two academics: Laurence Kotlikoff, who was an advisor to Ronald Reagan, and his brother Michael Kotlikoff, who is the provost of Cornell. Their plan is to swab everyone twice, and pool one of the tests into groups of up to a thousand people. You test that pool as a whole, and if it comes back negative then everyone gets a wristband that lets them go to work. If the pool test comes back positive, then you test each individual swab, find the infected individuals, and quarantine them, while everyone else gets to go to work. You repeat the process every week until the contagion is exterminated. They acknowledge that there are problems with scale and compliance, but their optimistic guess is that once implemented it could start getting America back to work within two weeks. 

  1. Human challenge trials

One of the biggest problems with waiting for a vaccine is the length of time it can take. As vaccine researchers have been telling journalists and warning the public for a few months now, 12-18 months for a vaccine is not slow, it is ridiculously fast -- the normal time for developing a vaccine is 10-15 years, with the phase three trials that determine the effectiveness of the vaccine taking up to three years on their own. 

A number of researchers have put out proposals to dramatically reduce that timeline.  A group out of Rutgers proposes to run a “human challenge” that would involve getting a group of  a hundred or so low-risk individuals, giving half the vaccine and half a placebo, then exposing them to the virus and seeing whether those who get the vaccine escape infection. A similar proposal published on Monday acknowledges the serious ethical questions in play and makes an effort to show how competing risks must be balanced. But it does not shy away from the urgency of the situation. 

  1. Look for a “natural vaccine”

Like all viruses the novel coronavirus mutates, and by studying the genetic differences between the different strains of the virus scientists can figure out where each strain originated. But Chinese researchers also appear to have discovered a strain that is milder than the strains that are infecting most people. And so, as the Australian microbiologist Dan Tillet argues, this opens up the possibility that there are mutant strains of COVID-19 that are asymptomatic or mild, but which are still infective and will provide immunity to the more pathogenic (deadly) strains.”

In effect, it would be like finding a natural version of the sort of live attenuated vaccines that are given for polio and for measles, mumps, and rubella. As he puts it, “If we can find one of these non-pathogenic viral strains out in the wild we could give it to everyone in the world and solve our diabolic problem.” 

  1. Controlled infection

The economist Robin Hanson doesn’t think we should be waiting for a less pathogenic strain of the virus, and he has been pushing for a form of controlled infection that he’s calling variolation. His argument is that since it seems likely now that almost everyone is eventually going to get infected, lockdowns only increase deaths by exposing people to very high doses of the virus from the members of their family who get infected. His proposal is that we can significantly cut the death rate through voluntary infection of relatively young and healthy people with a very low dose of the virus — as we used to do with smallpox. Hanson claims his modelling shows that controlled infection could cut deaths from COVID-19 by anywhere from three to 30 times.

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ARE THESE IDEAS RISKY? Of course they are. But the question isn’t whether they are risky or not, it is how risky they are compared with the current plan, which is to put our lives into suspended animation while we wait for a vaccine, betting everything on the capacity of the government to massively ramp up the testing and contact tracing of a substantially compliant citizenry, for an indefinite period of time. (AP)