Your advice in Tuesday’s Washington Post article, was excellent, but falls short in one very important regard: it fails to address the national leadership void we face on COVID-19, which is continuing to dramatically impact our national outcome.
It is not enough to lament that “demand for tests will probably exceed the supply for some time”. The president needs to invoke the Defense Production Act (DPA) now to immediately accelerate testing capacity and production of all needed healthcare supplies, including 100s of millions of masks for citizens — not only ventilators. This would enable proactive mass testing — to get ahead of the curve — and reduce the transmission rate when citizens interact in grocery stores and other enclosed public spaces. This point should have been stated and forcefully driven home. The whole purpose of the DPA is to help address national emergencies!
Furthermore, there are many other important policy and other actions that our leadership could take, that would help against this disaster, but you did not mention, presumably because your focus has been on the technical challenge. You could mitigate this blind spot by teaming up with some governors.
Please consider leading a Coronavirus Action Team, with 3-5 governors, to quickly devise and implement effective nationwide action plans, since the federal government has been too slow and ineffective, and thousands of Americans will die unnecessarily as a result.
Please join with a few governors, both: (a) to be more aware of the levers of influence that are available — both federal and state; and (b) to build a critical mass COVID-19 leadership team that the nation sorely needs. We are already facing thousands of unnecessary deaths, because of the disastrous federal leadership void. Please help us avoid more.
Millions are now sitting at home, waiting our turns to play Russian roulette with COVID-19, while the economy and our social lives are in deep freeze.
To safely ease back to normalcy, we need to simultaneously: (a) prevent healthcare system overload and reduce unnecessary deaths; and (b) allow society — and the economy — to resume functioning. This balancing act will involve a protracted game of whack-a-mole with the virus, and the cost will be high, but it is far better than the alternatives.
There are four keys to achieve this balance, described below. USA’s recently enacted $2.2 trillion bailout will be wasted if these urgent actions are not taken.
⚓1. Free proactive mass testing. We need to rapidly test hundreds of millions — not mere thousands or millions — to detect silent spreaders and identify hot spot areas that need greater isolation. This is crucial because it enables restrictions to be targeted to the areas and individuals where and when they are needed, allowing other areas and individuals to function semi-normally. “You cannot fight a fire blindfolded.” Unfortunately, so far the USA’s focus has been on individual testing — after infection is already suspected — but that is too little and too late to stop the silent spreaders. Proactive mass testing should include:
⚓Make testing free. If the USA can afford a $2.2 trillion economic bailout, we can certainly afford the tests that will allow the economy to start moving again. Testing capacity needs to be ramped-up on an emergency basis, invoking the Defense Production Act if necessary. And all barriers to testing need to be removed, including threat of reprisal such as deportation.
⚓Test front-line workers daily — not only healthcare workers, but police, bus drivers, cashiers, etc. — anyone who works in close proximity with the public.
⚓Test everyone in areas that exceed a risk threshold that is determined by epidemiologists — not politicians. It can even be done door-to-door if needed.
⚓Improve testing technology, to be easier, safer, faster and more acceptable to the public. For example, a home nasal swab test is awaiting FDA approval. Faster, more palatable testing may be more effective than slower, more precise results. This trade-off needs to be calculated based on best-available evidence — not gut instinct.
⚓Mandate uniform county-level case reporting, in a standard machine-processable CSV format, at a stable URL for each state, and automatically aggregated at the national level in real time. This would be super easy to do, and it would help by giving us public health workers up-to-date intelligence.
⚓2. Comprehensive contact tracing — including second-generation tracing. This involves lots of human labor — China used over 1800 teams of 5 in Wuhan alone — but we cannot be stingy about it. This work should done by trained volunteers and others — not by doctors and nurses who are urgently needed on the front lines of treatment. We should also use technology to help, provided that privacy considerations are appropriately considered. For example, an open source privacy-respecting app could be developed, along the lines of Singapore’s Trace Together. Several independent app development efforts are under way — see lists here and here — but they should have state and federal support.
⚓3. Greater transmission prevention. This includes any measures, other than isolation, that reduce virus transmission, such as personal protective equipment, improved disinfection practices, and rules regarding workplaces and public places. Many actions are possible, including:
⚓Require public transport riders and workers to wear a mask and sanitize hands on entry and exit.
⚓Dramatically increase public transport capacity, to increase space between passengers.
⚓Continuously disinfect public transport and other public and semi-public areas — not merely once a day or once every 4 hours.
⚓Require front-line workers to wear masks — not only healthcare workers, but police, bus drivers, cashiers, etc. — anyone who must work in close proximity to the public.
⚓Require a mask and hand sanitizing to enter any workplace or enclosed public place.
⚓Require proof of recent (24 hour) negative test or immunity, as a condition of entry to workplaces, restaurants, theaters, etc.
⚓Require testing at borders, with daily follow-up testing and limited travel and contact for 14-days. If necessary, this could even be extended temporarily to certain domestic areas, such as outbreak hotspots or safe zones.
⚓4. Selective isolation. This applies both to individuals who may be infected, and to areas that need to enact temporary lockdowns when outbreaks occur. Since there is no effective treatment to cure COVID-19, isolation (quarantine) is still a vital component. Even in a free country, nobody has the right to spread disease. But proactive mass testing and comprehensive contact tracing enables isolation to be applied intelligently, only where/when needed.
Healthcare experts should measure the effectiveness of each of these measures and adjust or add new ones as appropriate.
Finally, actions at the national level should include:
⚓Form a Coronavirus Action Team, sponsored by 3-5 courageous state governors, to devise and coordinate effective action — nationally. Normally this would be done at the federal level, but we cannot afford more delay, downplaying and half measures against an exponentially growing disaster. Already thousands will diehave died unnecessarily, as a direct result of the federal government’s inaction and ineffective action. We must not let more die unnecessarily due to even more delays and half measures. Governors should step forward to fill this leadership void instead, since they must act anyway, on behalf of their states. The core group needs to be small and fast, because speed is critical, but other governors should sign on as well, as supporters. The group should immediately assemble a tiger team of experts who understand the COVID-19 successes and failures of other countries, and can think outside the box to devise bold effective measures. Read more here. Incidentally, Bill Gates would be an excellent choice to lead this tiger team. He has also been immersed in the science of epidemics for years, with the Gates Foundation, and five years ago predicted this pandemic.
⚓Launch a coronavirus public works program. We already have millions of Americans out of work, who could immediately help with testing, case tracking, cleaning and sanitizing, manufacturing medical masks and equipment, preparing temporary COVID-19 overflow hospitals in unused buildings, delivering food and medicine to quarantined or at-risk people, etc. If needed, the program could also be extended to repair the nation’s crumbling infrastructure.
⚓Mobilize emergency production of coronavirus-related equipment, supplies and temporary hospitals. The Defense Production Act is for national emergencies. This is a national emergency. Every delay costs lives.
⚓Crowdsource ideas and action, supervised by qualified experts. We have millions of smart people sitting idle, who want to help. Crowdsourcing is especially good for generating creative ideas and parallelizing mundane tasks.
This will be a massive undertaking — that’s the price of failing to take effective action sooner — but it’s important, to allow our lives and the economy to safely resume. And this is not an exhaustive list. Obviously there are many more things that FEMA, the CDC, the FDA, HHS and others should be doing as well.
Everyone can help in this fight — especially the millions who are now stuck at home — and not only in the obvious ways like washing hands, social distancing and mask making. Please do two things: 1. share this information with others — as many as possible; and 2. contact state and local leaders to urge them to take these actions — now.
3/30/2020: Added crowdsourcing and made small edits. 4/5/2020: More small edits, and mentioned mask making. 4/8/2020: Added free testing bullet. 4/10/2020: Slight editing. 4/19/2020: Slight updates. 5/25/2020: Clarified that DPA can be used.
Social distancing measures currently keep millions self-quarantined in their homes in an emergency effort to slow the spread of COVID-19 coronavirus. It will only be safe to resume normal work and social activities when we can distinguish those who are infected from those who are not. And this requires testing.
After absurd delays and refusal to use tests developed by other countries, the US is slowly ramping up COVID-19 coronavirus testing. Unfortunately there is still a major disconnect in the nation’s testing strategy: the focus is still on individual testing, instead of mass testing.
It is too late to be testing only when someone is already symptomatic enough to be a suspected case. To detect the silent spreaders and get ahead of the curve, we need to be testing everyone. This requires mass testing — 100s of millions, not thousands — using economical, high-throughput techniques.
One way to multiply test throughput and reduce cost is to use sample pooling, which a research team at Technion University has recently shown to work for COVID-19 testing. Sample pooling enables a large number of samples to be screened at once, using only a few tests. It works by taking a small portion of each sample, and mixing those portions together in separate “pools”. In the illustration above, 64 samples are divided into two pools of 32 samples. Each pool is then tested. If a pool tests negative, then all 32 samples in that pool are considered negative: there is no need to test them further. But if a pool tests positive, then more testing is needed. If it is a small pool, then each sample is re-tested individually (using the remaining portion), to determine which individual samples are positive. But in some protocols, if the pool is still large, it can be further subdivided into another set of smaller pools, and the process repeated. This technique works on large populations that contain relatively few positives, which is what we need for mass COVID-19 screening. There are many variations.
Sample pooling is not the only way to achieve inexpensive high-throughput testing, and it is not applicable to all testing protocols. But it is certainly a technique that should be considered, instead of myopically focusing on individual testing.
Social distancing is an essential emergency measure, to slow the exponential growth of the outbreak. But it is not enough to bring the outbreak under control. To detect the silent spreaders and get ahead of the curve, we need mass testing, and we need it now.
3/27/2020: Edited to better mention social distancing, and to clarify that sample pooling is not applicable to all testing protocols.
USA’s response has been even slower and less effective than Italy’s
Even Italy responded faster and more effectively than the USA has, to slow the explosive growth of its coronavirus (COVID-19) outbreak. The USA’s failure to take rapid effective action against this exponentially growing outbreak is hurtling the nation toward disaster — a disaster far larger than it needed to be.
Figure 1 compares the effectiveness of four countries — USA, Italy, China and South Korea — in responding to its COVID-19 outbreak. For each country, it plots the average count of confirmed new cases on a timeline that begins on the day when that country surpassed a threshold of 100 confirmed cases — the “start” of its outbreak, for comparison purposes. The relative speed and effectiveness of each country’s efforts to combat the outbreak can be seen by observing the average count of new cases since the start of its outbreak.
By day 18 of its outbreak, the USA had surpassed all three countries in its average new case load, even though its average was lower than the others for the first 12 days. As of this writing (day 22) the USA’s average new case load continued to soar unchecked, while Italy and China had made substantial progress in reducing theirs. In stark contrast, South Korea’s rapid response to its outbreak was very effective. By day 13 its average new case load was already declining, and by day 25 it was below 100.
The above graph makes no estimates or modeling assumptions whatsoever. And it uses only official, confirmed case counts. You can easily examine the spreadsheet yourself.
This failure, by the richest, most powerful nation in the world, to take rapid effective action against an exponentially growing disease outbreak is inexcusable. Instead of learning from the COVID-19 successes and failures in other countries such as China, South Korea and Italy, and heeding the urgent calls of the WHO and many other epidemiology experts, the US administration wasted precious weeks downplaying the threat. The result is an imminent national disaster, on a scale much larger than it needed to be.
There is a legal term for this failure to act: criminal negligence.
However, the battle is not over, and the outcome depends on our ability to take massive, bold, effective action — now. In the absence of effective federal leadership, we need one courageous state governor to step forward and lead the charge, to stop the uncontrolled spread of this disease and reduce the magnitude of this disaster. See Stopping COVID-19: Who will fill the leadership void?
3/29/2020: Minor editorial changes. 4/10/2020: Changed Italy body transport photo to Delay=Death image.
To effectively mitigate or stop a rapidly spreading epidemic, it is essential to bring the outbreak’s growth rate down — fast. With an exponential growth rate, every day of delay — every hour of delay — has an enormous downstream impact.
The figure above graphically demonstrates how slow and ineffective the USA has been in responding to its COVID-19 outbreak, in comparison with China, South Korea and Italy. For example, South Korea (dotted gray line), which had an explosive off-the-chart 5-day growth rate in its first several days, brought its average new case load down to almost zero by its day 20, indicating that its actions were very effective in bringing the outbreak under control. In contrast the average count of new confirmed cases in USA on day 20 was still skyrocketing — far higher than it was in China or even Italy on its day 20.
Because of the USA administration’s failure to lead this country to take immediate effective action against COVID-19, a national disaster is now inevitable. The cost of this leadership failure is staggering: many thousands will die, and millions are losing their jobs. Trillion-dollar bail-outs are already in discussion.
However, as China has shown, even at this relatively late stage,we can still stop COVID-19 — and dramatically reduce the magnitude of the damage — but it will require a massive effort. Is it worth the cost? Yes, because the alternatives are even worse. Furthermore, the massive effort itself will help to heal the injured economy.
To best pull this off, we need effective national leadership with a will to do it, which we obviously don’t have in the current administration. But there is an alternative: our state governors.
We need one courageous governor to immediately step forward and take the lead nationally against COVID-19. Here’s how:
Select and lead a core group of 3-5 influential, big-state governors who are willing to take dramatic, effective action. Keep this core group small and fast. With exponential growth, speed is essential.
Create a virtual Coronavirus Action Team. Zoom, google docs and the Web are our friends in this time of social distancing.
Form a tiger team of top experts and trail blazers who:
understand COVID-19 successes in China, South Korea, Singapore, Taiwan, etc.;
believe we can stop it — no “it’s too late” defeatists;
are willing to make this emergency their top 24/7 priority; and
can think outside the box and devise bold effective measures to stop it.
Set up a 24/7 support team, to assist the tiger team in any ways needed, including data analysis, messaging, website creation, public relations, and managing ideas and feedback from the public.
Hold press conferences every 2-4 hours, to keep the media focus, and always give accurate, unbiased information.
Be a consistent, national public face of effective COVID-19 action.
This core group of influential governors would act as the executive arm of the Coronavirus Action Team, to:
Support the team with all resources and influence needed (making connections, removing barriers, etc.);
Mobilize resources and implement recommended measures;
Marshal medical equipment and testing manufacturers as needed, on an emergency basis;
Pressure the federal government for any help needed, without deferring to the federal government or waiting for it (because we have already seen what a disaster that has been);
Get any necessary emergency legislation passed;
Keep the public informed, 24/7, with accurate unbiased information; and
Engage other state governors to join as supporters — not as core team — and similarly take action.
The Coronavirus Action Team should also crowdsource ideas and action as much as possible, appropriately vetted and supervised. We have millions of smart people sitting idle, wanting to help.
Who is willing to step forward, to fill this urgently needed leadership void?
3/30/2020: Added crowdsourcing and updated the team name.
3/26/2020: Edited to use a different graphic that is easier to understand.
WARNING: If you are not a math whiz, and you don’t understand exponentials very well, the above graph may look deceptively optimistic. Read on to understand why.
The above graph compares how quickly and effectively each country responded to its COVID-19 outbreak, by measuring the outbreak’s growth rate in the 30 days following its start. It shows that USA lags far behind China, South Korea and even Italy, in its efforts to stop the explosive spread.
In this graph, the start of each country’s outbreak is considered to be the day when that country exceeded 100 confirmed COVID-19 cases: day 0. For each day thereafter, the 5-day growth rate is plotted for each country. This allows us to compare the relative effectiveness of each country’s efforts.
The 5-day growth rate is calculated as the percent increase of confirmed cases reported for that day, as compared with the number reported 5 days prior. For example, a growth rate of 100% means that the number of cases doubled in 5 days — a 100% increase from 5 days prior — an explosive growth rate.
As each country responded to its outbreak, the effectiveness of its actions (or inaction) can be seen by observing how quickly and how much it succeeded in reduced the growth rate. For example, South Korea started with an astronomical, off-the-chart growth rate (dotted gray line) in the first 5 days of its outbreak. But by day 13 its aggressive actions to stop the spread had succeeded in lowering the growth rate to about 100%, and by day 20 the growth rate was nearly zero: the outbreak was under control. In contrast, the 5-day growth rate in the USA on day 20 was still 463%. This clearly shows that the USA has been considerably slower and less effective in responding to its outbreak than China, South Korea and even Italy, in spite of the fact that it had weeks of extra lead time to learn from the successes and failures of those countries.
Note this data analysis makes no modeling assumptions or estimates whatsoever. None. Zip. Nada. It uses only officially reported, confirmed COVID-19 case counts.
One tiny glimmer of good news is that the social distancing measures initiated by some state and local governments are starting to help. As of this writing (day 21) the USA’s 5-day growth rate had dropped to just under 300%.UPDATE: As of yesterday (day 27) the USA’s 5-day growth rate had dropped to 146%.
The bad news is that 300% is still an explosively high growth rate.UPDATE: The bad news is that 146% is still an explosively high growth rate. That is more than doubling every 5 days!
This failure by the USA to take rapid effective action to stop the exponential spread of COVID-19 has guaranteed that the USA will now face a national disaster that is much larger than it needed to be.