1  Here’s the Deal

1. We need readily-available PPE of the appropriate kinds. This includes class-95 respirators (N95 / KN95 / FFP2). It also includes face shields, gowns, gloves, and other gear.
2. We need mandatory masking and distancing. This includes staying home as much as possible, and wearing effective masks when not at home. It also includes banning high-risk gatherings.
3. We need comprehensive, reliable, timely testing.
4. We need contact tracing, so we can focus the testing resources where they are most needed, where they will be most informative. A great many tracers are needed; see reference 1.
5. We need surveillance of the general population, as discussed in section 3.
6. We need subcritical isolation facilities, so we can isolate everyone who might be contagious, so we don’t need to isolate everybody else, and so we don’t send infected people home to kill their families.
7. We need education and training and leadership, to persuade (and if necessary compel) people to adopt the proper behaviors.
8. In places where the outbreak is out of control, we need a mandatory stay-at-home order. Everybody stays at home until the case load drops to a point where the test-and-trace program can keep up with it.
9. And a few other things.

We know what’s needed. We know this based on modeling, and based on observations of countries that have successfully suppressed the virus. See e.g. reference 2.

Let’s be clear: A lockdown won’t solve the problem by itself. A lockdown is like a tourniquet. If-and-when you need one:

• It can be applied quickly. No great skill is needed.
• It is temporary. You still need skilled surgery, real soon.
• Even while it is saving your life, it causes injury.

So it is not (and never was) primarily a question of lockdown versus no lockdown, or longer versus shorter lockdown, or stricter versus looser. The point of a lockdown is (and always was) to buy time to implement all the other measures that are needed. So far enormous amounts of time, lives, and treasure have been squandered. We don’t have what is needed, and we’re not even on a path to get it any time soon.

2  Play to Win

2.1  Save One, Save All

We must reject the Libertarian or Hobbesian notion that each person should protect himself, without regard to others.

In fact, the only reasonable way to save yourself is to save everbody. That is, suppress the virus hard and fast. Play to win.

To say the same thing the other way: Hoping that some people will play it safe while many others run wild is not a winning strategy. It means there is a Petri dish where the virus can grow. Making the dish slightly smaller will not defeat the virus.

There is not enough PPE in the whole world to protect yourself while the virus rages outside. Edgar Allan Poe wrote a story about this: The Masque of the Red Death. It does not end well.

The amount of virus in circulation tends to increase exponentially or decrease exponentially. This means that seemingly-small changes in behavior can have enormous consequences. It’s nonlinear. Most people find this highly counterintuitive. For more on this, see reference 3.

2.2  Saving Lives and Protecting the Economy

The best way to save lives and protect the economy is to suppress the outbreak as quickly as possible. In other words, drive the incidence all the way to zero. Don’t just flatten the curve. Don’t settle for a Vietnam-war-style stalemate. Play to win. This is how it was done in every country that has successfully dealt with the virus.

To say the same thing the other way: Do not frame it as a choice between economic ruin and mass slaughter. That is a false choice! Never put yourself in a situation where you have to choose which of your children you have to kill. Plan ahead so you stay out of all such situations.

Churchill said of Chamberlain (1938):

“You were given the choice between war and dishonor.
You chose dishonor and you will have war.”

Today’s situation is so very much more scandalous. Chamberlain faced a genuinely tough choice, whereas the #pussygrabber did not. His dishonorable narcissism and mendacity created a false choice between economic ruin and mass slaughter, neither of which was necessary.

3  Surveillance, Including Temperature Checking

1. From the public-health point of view, the central goal is to stop the spread of the disease.
   • Temperature checks don’t catch all infections, but they catch some, and that contributes to lowering the lower the reproduction number, R. This is nowhere near sufficient by itself, but it contributes. It’s not an either/or situation.
   • Temperature checking makes more sense in places where they have facilities to isolate people who might be contagious, rather than sending them home to kill their families. We should have set this up in February. It’s now late October. We don’t have what we need, and we’re not even on a path to get it any time soon.
   • Temperature checking is very cheap, very rapid, and can be very widely deployed. So it complements other methods that are much more expensive, much less timely, and not widely deployed. Again, it’s not an either/or situation.
   • The R value is not the whole story, because the disease spreads very unevenly. It turns out there is a role for quick, cheap tests, even if they have less than 100% sensitivity, as one part of the larger picture, for reasons spelled out beautifully in reference 4.
2. We now turn to the patient-by-patient point of view. (This is unlike the public health point of view, which can invoke the law of averages, averaging over many people to get an R value for the population. Different questions require different answers.)
   • If you want to know with high confidence whether a particular person is infected, temperature checking is not good enough.

Bottom line: We should be doing a lot more temperature checking. We should also be doing a lot more PCR testing. Orders of magnitude more. Also subcritical isolation, and a lot of other things, as discussed in section 1.

Surveillance and contact-tracing and other defensive public-health measures are easy when the disease is rare, and impossibly hard when it is highly prevalent. So it is important to suppress the virus to a very low level. To say the same thing the other way, if you relax when it gets down to a moderately low level, it will come roaring back. This has been understood since the earliest days (reference 5).

4  Appendix: WHO Guidelines

Here are the WHO criteria for deciding whether and when to loosen shelter-in-place restrictions (reference 6):

• first, that transmission is controlled;
• second, that health system capacities are in place to detect, test, isolate and treat every case and trace every contact;
• third, that outbreak risks are minimised in special settings like health facilities and nursing homes;
• fourth, that preventive measures are in place in workplaces, schools and other places where it’s essential for people to go;
• fifth, that importation risks can be managed; and
• sixth, that communities are fully educated, engaged and empowered to adjust to the new norm.

5  References

1.

Contact Tracing Workforce Estimator
https://www.gwhwi.org/estimator-613404.html

2.

Donald McNeil
“Coronavirus Can Be Stopped Only by Harsh Steps, Experts Say”
https://www.nytimes.com/2020/03/22/health/coronavirus-restrictions-us.html

3.

“The Sum of Exponentials”
www.av8n.com/politics/sum-of-exponentials.htm

4.

Zeynep Tufekci, “This Overlooked Variable Is the Key to the Pandemic”
https://www.theatlantic.com/health/archive/2020/09/k-overlooked-variable-driving-pandemic/616548/

5.

Tomas Pueyo,
“Coronavirus: The Hammer and the Dance”
“What the Next 18 Months Can Look Like, if Leaders Buy Us Time” (Mar 19, 2020)
https://tomaspueyo.medium.com/coronavirus-the-hammer-and-the-dance-be9337092b56

6.

WHO criteria for deciding whether and when to loosen shelter-in-place restrictions:
https://www.who.int/docs/default-source/coronaviruse/transcripts/who-audio-emergencies-coronavirus-press-conference-13apr2020.pdf