Under a suppression strategy, after the first wave is done, the death toll is in the thousands, and not in the millions.

Why? Because not only do we cut the exponential growth of cases. We also cut the fatality rate since the healthcare system is not completely overwhelmed. Here, I used a fatality rate of 0.9%, around what we’re seeing in South Korea today, which has been most effective at following Suppression Strategy.

Said like this, it sounds like a no-brainer. Everybody should follow the Suppression Strategy.

So why do some governments hesitate?

They fear three things:

1. This first lockdown will last for months, which seems unacceptable for many people.
2. A months-long lockdown would destroy the economy.
3. It wouldn’t even solve the problem, because we would be just postponing the epidemic: later on, once we release the social distancing measures, people will still get infected in the millions and die.

Here is how the Imperial College team modeled suppressions. The green and yellow lines are different scenarios of Suppression. You can see that doesn’t look good: We still get huge peaks, so why bother?

We’ll get to these questions in a moment, but there’s something more important before.

This is completely missing the point.

Presented like these, the two options of Mitigation and Suppression, side by side, don’t look very appealing. Either a lot of people die soon and we don’t hurt the economy today, or we hurt the economy today, just to postpone the deaths.

This ignores the value of time.

3. The Value of Time

In our previous post, we explained the value of time in saving lives. Every day, every hour we waited to take measures, this exponential threat continued spreading. We saw how a single day could reduce the total cases by 40% and the death toll by even more.

But time is even more valuable than that.

We’re about to face the biggest wave of pressure on the healthcare system ever seen in history. We are completely unprepared, facing an enemy we don’t know. That is not a good position for war.

What if you were about to face your worst enemy, of which you knew very little, and you had two options: Either you run towards it, or you escape to buy yourself a bit of time to prepare. Which one would you choose?

This is what we need to do today. The world has awakened. Every single day we delay the coronavirus, we can get better prepared. The next sections detail what that time would buy us:

Lower the Number of Cases

With effective suppression, the number of true cases would plummet overnight, as we saw in Hubei last week.

As of today, there are 0 daily new cases of coronavirus in the entire 60 million-big region of Hubei.

The diagnostics would keep going up for a couple of weeks, but then they would start going down. With fewer cases, the fatality rate starts dropping too. And the collateral damage is also reduced: fewer people would die from non-coronavirus-related causes because the healthcare system is simply overwhelmed.

Suppression would get us:

• Fewer total cases of Coronavirus
• Immediate relief for the healthcare system and the humans who run it
• Reduction in fatality rate
• Reduction in collateral damage
• Ability for infected, isolated and quarantined healthcare workers to get better and back to work. In Italy, healthcare workers represent 8% of all contagions.

Understand the True Problem: Testing and Tracing

Right now, the UK and the US have no idea about their true cases. We don’t know how many there are. We just know the official number is not right, and the true one is in the tens of thousands of cases. This has happened because we’re not testing, and we’re not tracing.

• With a few more weeks, we could get our testing situation in order, and start testing everybody. With that information, we would finally know the true extent of the problem, where we need to be more aggressive, and what communities are safe to be released from a lockdown.
• New testing methods could speed up testing and drive costs down substantially.
• We could also set up a tracing operation like the ones they have in China or other East Asia countries, where they can identify all the people that every sick person met, and can put them in quarantine. This would give us a ton of intelligence to release later on our social distancing measures: if we know where the virus is, we can target these places only. This is not rocket science: it’s the basics of how East Asia Countries have been able to control this outbreak without the kind of draconian social distancing that is increasingly essential in other countries.

The measures from this section (testing and tracing) single-handedly curbed the growth of the coronavirus in South Korea and got the epidemic under control, without a strong imposition of social distancing measures.

Build Up Capacity

The US (and presumably the UK) are about to go to war without armor.

We have masks for just two weeks, few personal protective equipments (“PPE”), not enough ventilators, not enough ICU beds, not enough ECMOs (blood oxygenation machines)… This is why the fatality rate would be so high in a mitigation strategy.

But if we buy ourselves some time, we can turn this around:

• We have more time to buy equipment we will need for a future wave
• We can quickly build up our production of masks, PPEs, ventilators, ECMOs, and any other critical device to reduce fatality rate.

Put in another way: we don’t need years to get our armor, we need weeks. Let’s do everything we can to get our production humming now. Countries are mobilized. People are being inventive, such as using 3D printing for ventilator parts. We can do it. We just need more time. Would you wait a few weeks to get yourself some armor before facing a mortal enemy?

This is not the only capacity we need. We will need health workers as soon as possible. Where will we get them? We need to train people to assist nurses, and we need to get medical workers out of retirement. Many countries have already started, but this takes time. We can do this in a few weeks, but not if everything collapses.

Lower Public Contagiousness

The public is scared. The coronavirus is new. There’s so much we don’t know how to do yet! People haven’t learned to stop hand-shaking. They still hug. They don’t open doors with their elbow. They don’t wash their hands after touching a door knob. They don’t disinfect tables before sitting.

Once we have enough masks, we can use them outside of the healthcare system too. Right now, it’s better to keep them for healthcare workers. But if they weren’t scarce, people should wear them in their daily lives, making it less likely that they infect other people when sick, and with proper training also reducing the likelihood that the wearers get infected. (In the meantime, wearing something is better than nothing.)

All of these are pretty cheap ways to reduce the transmission rate. The less this virus propagates, the fewer measures we’ll need in the future to contain it. But we need time to educate people on all these measures and equip them.

Understand the Virus

We know very very little about the virus. But every week, hundreds of new papers are coming.

The world is finally united against a common enemy. Researchers around the globe are mobilizing to understand this virus better.

How does the virus spread?
How can contagion be slowed down?
What is the share of asymptomatic carriers?
Are they contagious? How much?
What are good treatments?
How long does it survive?
On what surfaces?
How do different social distancing measures impact the transmission rate?
What’s their cost?
What are tracing best practices?
How reliable are our tests?

Clear answers to these questions will help make our response as targeted as possible while minimizing collateral economic and social damage. And they will come in weeks, not years.

Find Treatments

Not only that, but what if we found a treatment in the next few weeks? Any day we buy gets us closer to that. Right now, there are already several candidates, such as Favipiravir, Chloroquine, or Chloroquine combined with Azithromycin. What if it turned out that in two months we discovered a treatment for the coronavirus? How stupid would we look if we already had millions of deaths following a mitigation strategy?

Understand the Cost-Benefits

All of the factors above can help us save millions of lives. That should be enough. Unfortunately, politicians can’t only think about the lives of the infected. They must think about all the population, and heavy social distancing measures have an impact on others.

Right now we have no idea how different social distancing measures reduce transmission. We also have no clue what their economic and social costs are.

Isn’t it a bit difficult to decide what measures we need for the long term if we don’t know their cost or benefit?

A few weeks would give us enough time to start studying them, understand them, prioritize them, and decide which ones to follow.

Fewer cases, more understanding of the problem, building up assets, understanding the virus, understanding the cost-benefit of different measures, educating the public… These are some core tools to fight the virus, and we just need a few weeks to develop many of them. Wouldn’t it be dumb to commit to a strategy that throws us instead, unprepared, into the jaws of our enemy?

4. The Hammer and the Dance

Now we know that the Mitigation Strategy is probably a terrible choice, and that the Suppression Strategy has a massive short-term advantage.

But people have rightful concerns about this strategy:

• How long will it actually last?
• How expensive will it be?
• Will there be a second peak as big as if we didn’t do anything?

Here, we’re going to look at what a true Suppression Strategy would look like. We can call it the Hammer and the Dance.

The Hammer

First, you act quickly and aggressively. For all the reasons we mentioned above, given the value of time, we want to quench this thing as soon as possible.

One of the most important questions is: How long will this last?

The fear that everybody has is that we will be locked inside our homes for months at a time, with the ensuing economic disaster and mental breakdowns. This idea was unfortunately entertained in the famous Imperial College paper:

Do you remember this chart? The light blue area that goes from end of March to end of August is the period that the paper recommends as the Hammer, the initial suppression that includes heavy social distancing.

If you’re a politician and you see that one option is to let hundreds of thousands or millions of people die with a mitigation strategy and the other is to stop the economy for five months before going through the same peak of cases and deaths, these don’t sound like compelling options.

But this doesn’t need to be so. This paper, driving policy today, has been brutally criticized for core flaws: They ignore contact tracing (at the core of policies in South Korea, China or Singapore among others) or travel restrictions (critical in China), ignore the impact of big crowds…

The time needed for the Hammer is weeks, not months.

This graph shows the new cases in the entire Hubei region (60 million people) every day since 1/23. Within 2 weeks, the country was starting to get back to work. Within ~5 weeks it was completely under control. And within 7 weeks the new diagnostics was just a trickle. Let’s remember this was the worst region in China.

Remember again that these are the orange bars. The grey bars, the true cases, had plummeted much earlier (see Chart 9).

The measures they took were pretty similar to the ones taken in Italy, Spain or France: isolations, quarantines, people had to stay at home unless there was an emergency or had to buy food, contact tracing, testing, more hospital beds, travel bans…

Details matter, however.

China’s measures were stronger. For example, people were limited to one person per household allowed to leave home every three days to buy food. Also, their enforcement was severe. It is likely that this severity stopped the epidemic faster.

In Italy, France and Spain, measures were not as drastic, and their implementation is not as tough. People still walk on the streets, many without masks. This is likely to result in a slower Hammer: more time to fully control the epidemic.

Some people interpret this as “Democracies will never be able to replicate this reduction in cases”. That’s wrong.

For several weeks, South Korea had the worst epidemic outside of China. Now, it’s largely under control. And they did it without asking people to stay home. They achieved it mostly with very aggressive testing, contact tracing, and enforced quarantines and isolations.

The following table gives a good sense of what measures different countries have followed, and how that has impacted them (this is a work-in-progress. Feedback welcome.)

This shows how countries who were prepared, with stronger epidemiological authority, education on hygiene and social distancing, and early detection and isolation, didn’t have to pay with heavier measures afterwards.

Conversely, countries like Italy, Spain or France weren’t doing these well, and had to then apply the Hammer with the hard measures at the bottom to catch up.

The lack of measures in the US and UK is in stark contrast, especially in the US. These countries are still not doing what allowed Singapore, South Korea or Taiwan to control the virus, despite their outbreaks growing exponentially. But it’s a matter of time. Either they have a massive epidemic, or they realize late their mistake, and have to overcompensate with a heavier Hammer. There is no escape from this.

But it’s doable. If an outbreak like South Korea’s can be controlled in weeks and without mandated social distancing, Western countries, which are already applying a heavy Hammer with strict social distancing measures, can definitely control the outbreak within weeks. It’s a matter of discipline, execution, and how much the population abides by the rules.

Once the Hammer is in place and the outbreak is controlled, the second phase begins: the Dance.

The Dance

If you hammer the coronavirus, within a few weeks you’ve controlled it and you’re in much better shape to address it. Now comes the longer-term effort to keep this virus contained until there’s a vaccine.

This is probably the single biggest, most important mistake people make when thinking about this stage: they think it will keep them home for months. This is not the case at all. In fact, it is likely that our lives will go back to close to normal.

The Dance in Successful Countries

How come South Korea, Singapore, Taiwan and Japan have had cases for a long time, in the case of South Korea thousands of them, and yet they’re not locked down home?

In this video, the South Korea Foreign Minister explains how her country did it. It was pretty simple: efficient testing, efficient tracing, travel bans, efficient isolating and efficient quarantining.

This paper explains Singapore’s approach:

Want to guess their measures? The same ones as in South Korea. In their case, they complemented with economic help to those in quarantine and travel bans and delays.

Is it too late for these countries and others? No. By applying the Hammer, they’re getting a new chance, a new shot at doing this right. The more they wait, the heavier and longer the hammer, but it can control the epidemics.

But what if all these measures aren’t enough?

The Dance of R

I call the months-long period between the Hammer and a vaccine or effective treatment the Dance because it won’t be a period during which measures are always the same harsh ones. Some regions will see outbreaks again, others won’t for long periods of time. Depending on how cases evolve, we will need to tighten up social distancing measures or we will be able to release them. That is the dance of R: a dance of measures between getting our lives back on track and spreading the disease, one of economy vs. healthcare.

How does this dance work?

It all turns around the R. If you remember, it’s the transmission rate. Early on in a standard, unprepared country, it’s somewhere between 2 and 3: During the few weeks that somebody is infected, they infect between 2 and 3 other people on average.

If R is above 1, infections grow exponentially into an epidemic. If it’s below 1, they die down.

During the Hammer, the goal is to get R as close to zero, as fast as possible, to quench the epidemic. In Wuhan, it is calculated that R was initially 3.9, and after the lockdown and centralized quarantine, it went down to 0.32.

But once you move into the Dance, you don’t need to do that anymore. You just need your R to stay below 1: a lot of the social distancing measures have true, hard costs on people. They might lose their job, their business, their healthy habits…

You can remain below R=1 with a few simple measures.

This is an approximation of how different types of patients respond to the virus, as well as their contagiousness. Nobody knows the true shape of this curve, but we’ve gathered data from different papers to approximate how it looks like.

Every day after they contract the virus, people have some contagion potential. Together, all these days of contagion add up to 2.5 contagions on average.

It is believed that there are some contagions already happening during the “no symptoms” phase. After that, as symptoms grow, usually people go to the doctor, get diagnosed, and their contagiousness diminishes.

For example, early on you have the virus but no symptoms, so you behave as normal. When you speak with people, you spread the virus. When you touch your nose and then open door knob, the next people to open the door and touch their nose get infected.

The more the virus is growing inside you, the more infectious you are. Then, once you start having symptoms, you might slowly stop going to work, stay in bed, wear a mask, or start going to the doctor. The bigger the symptoms, the more you distance yourself socially, reducing the spread of the virus.

Once you’re hospitalized, even if you are very contagious you don’t tend to spread the virus as much since you’re isolated.

This is where you can see the massive impact of policies like those of Singapore or South Korea:

• If people are massively tested, they can be identified even before they have symptoms. Quarantined, they can’t spread anything.
• If people are trained to identify their symptoms earlier, they reduce the number of days in blue, and hence their overall contagiousness
• If people are isolated as soon as they have symptoms, the contagions from the orange phase disappear.
• If people are educated about personal distance, mask-wearing, washing hands or disinfecting spaces, they spread less virus throughout the entire period.

Only when all these fail do we need heavier social distancing measures.

The ROI of Social Distancing

If with all these measures we’re still way above R=1, we need to reduce the average number of people that each person meets.

There are some very cheap ways to do that, like banning events with more than a certain number of people (eg, 50, 500), or asking people to work from home when they can.

Other are much, much more expensive economically, socially and ethically, such as closing schools and universities, asking everybody to stay home, or closing businesses.