Amid the constant news about the coronavirus, both from science and from the markets, it is easy to lose sight of the most terrifying scenario of all: in which there is no magic solution. In this totally plausible situation, there would be no effective COVID-19 vaccine or transformative therapy; the combination of testing and contact tracking would not successfully suppress the outbreak; and the collective immunity would occur, if at all, only after millions of deaths worldwide.
Even raising this possibility is a major disappointment. But the fact that a result is terrible does not make it impossible.
Since the end of February, I have conducted about 20 interviews with epidemiologists and virologists such as Marc Lipsitch, Angela Rasmussen and Carl Bergstrom; economists like Paul Romer, Stefanie Stantcheva and Larry Summers; and leaders in the best hospitals and experts in government agencies whose names may not be known, but whose life has prepared for moments like this. Despite getting expert answers to dozens of my questions, the only question I haven’t been able to get an answer for is this: who, exactly, is planning the nightmare scenario where we never get a vaccine or breakthrough treatment. ?
Ideally, it would be the executive branch of the federal government, with its resources and a panoramic view of the problem. But the president, who is running for reelection, has every reason to insist on (unrealistic) optimism. In fact, the Administration has even discussed the dissolution of its working group on the coronavirus.
CDC and other public health agencies may be a good second option; but they are busy (rightly so) warning the public not to relax and let the virus spread uncontrollably. Not really a job for scientists: (understandably) devoting all their energy to finding vaccines and treatments. Governors only have the authority to plan in their individual state. And the Fed is tasked with trying to save jobs and markets, not model the end of the economy as we know it.
I am not one of those who enjoy the scenarios of the end of the world. However, realism absolutely requires considering every confluence of events that could occur with reasonable probability. If, in fact, there is no worst-case planning agency or department, this is a major governance failure..
The fact that about 90 vaccines are being explored, with some clinical trials, is exciting and stimulating. Better than 80 shots or 40 or five or none. The simple number tends to make us think that one or more will be successful. But the sum of many very low probability events does not necessarily translate into a high probability that one will succeed.
There has never been a successful mRNA vaccineHow are they testing Modern and others, released to market after approval. The same goes for a viral vector vaccine like the one the group in the Oxford University. And traditional vaccines often take many years to reach patients.
We have heard so many times that a vaccine will not be available for 18 months, that we might have begun to confuse that message with the very different idea that, after 18 months, a vaccine will be available..
Similarly, transformative therapies are far from guaranteed. In a preliminary study, Remdesivir reduced mortality in hospitalized patients with COVID-19 from 11.6% to 8%. That is statistically significant and could save lives. But even if it is replicated widely, it won’t mean a fundamental change in the way we accept the risks of contracting the disease. And when was the last time the word hydrochloroquine was heard?
The combination of testing and contact tracking is advertised as a mechanism to reopen the economy. The challenges here include the reality that large-scale testing is not available now and is unlikely to be soon.. Manual contact tracking is as good as the response rate, and the willingness and ability to contact people to isolate themselves. Digital contact tracking is new and raises challenging ethical questions, including around privacy. It is also true that it will only work if a large number of people who come into contact with infected people isolate themselves.
Then there is the little-debated question of whether tests plus contact tracking can be used to suppress a disease that has spread in the community on a massive scale like the new coronavirus. The combination is of classic application in situations where there are few cases and the disease has not yet spread widely; that was the situation in South Korea, where it appears to have been highly effective. The technique is also said to have been shown to be effective in the 2014 Ebola outbreak. But epidemiologists I have spoken to about the new coronavirus have been unable to provide a truly comparable case in which testing and follow-up of contacts stopped a disease spread over a wide geographical area.
As usual, when all other scenarios have been discussed, the topic revolves around collective immunity. But how Bergstrom has been arguing for weeks, in practice that means that a large percentage of the population is exposed to the virus. Depending on the true death rate, that could mean many millions of deaths worldwide.
It is time to start thinking about how we should react to this horrible scenario. It is not defeatism to ask what the world will be like if we lose the war we are waging. It’s realism.
* The author is a professor of law at Harvard University and was secretary to the United States Supreme Court Justice David Souter.
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