Part 4 of a series on how the pandemic ends, and how we get there. Please share. Link to part 1, part 2, and part 3.

Ending the lockdown: Guiding principles

I am a scientist.

At least I identify as one. I haven’t been paid to actually do science since I finished my PhD, though I’ve been paid to teach science at a state university and to write about science for a local newspaper.

But I’m not only a scientist. I’m a human person. Like all of you, I have at times succumbed to one of the ways in which science gets misused. These include the following.

We ignore science because it conflicts with a belief system we have, or because it tells us something we don’t want to hear. Buy thousands of ventilators and then pay to have them sit around in a warehouse? What for?

We expect science to always be right, instead of a constantly emerging process of understanding that changes and corrects with new information. Yesterday you told me not to wear a mask. Today you say I should. Therefore I’m not going to listen to science.

We ask science to do things it cannot, like make decisions for us. “Nothing will reopen unless the science indicates it is safe to do so.”

If only it were that simple.

I know that laypeople cannot appreciate the scale of what the biomedical establishment has achieved in the past four months. To detect, identify, sequence, and test for a brand-new virus using RT-PCR (heck, to even know what a virus is); to be on the road to developing not one but dozens of potential vaccines using a range of techniques that have never been tried before; to create mathematical models that give us glimpses of possible futures; learning about cytokine storm and hypercoagulability in COVID patients; and so much more.

But in spite of the dazzling progress, pandemic science is still awash in uncertainty. And even where there is little doubt in the data, science by itself cannot tell us what to do. We must apply our values to make our choices.

Which is why reasonable people may disagree about the best path forward to living with coronavirus. Even if everyone is looking at the same data, our sense of the relative worth of one good over another colors our interpretation.

“Safe” is not a scientific concept. Aspects of safety can be measured and quantified using science. But the final assessment of “safe” is relative (“safe” compared to what alternative?) and is based on values.

With that in mind, let’s talk about re-opening.

I hope you’ve read my previous posts in this Coronavirus Endgame series, so that you understand how the pandemic is most likely to “end” in an equilibrium with the virus (part 1); what our current national strategy of social distancing can and cannot do (part 2); and that a strategy that includes herd immunity is possible (part 3).

Until now, I’ve tried to keep my writing as value-neutral as possible. I wanted to focus on the science in balanced ways that didn’t associate with either of the two big American tribes of red and blue. Believe me, that’s not easy in a world of hair-trigger sensitivity. In the next two posts, I will continue that attempt but by its very nature, this discussion will invoke values. I will try to label those bits, and clearly explain my underlying assumptions.

Because, you know, scientists have opinions too.

Guiding Principles

Back in mid-March, the US Centers for Disease Control (CDC) published a document entitled “Implementation of Mitigation Strategies for Communities with Local COVID-19 Transmission.” In it, CDC not only recommends mitigation activities, it also provides a list of principles, or values, to guide the choices that must be made. I think this is very helpful as these also apply to re-opening. Here are some of the CDC’s guiding principles, in quotes. I have summarized the spirit of each.

• Allow for local variation.

“Each community is unique, and appropriate mitigation strategies will vary based on the level of community transmission, characteristics of the community and their populations, and the local capacity to implement strategies.”

• Encourage flexibility to change course

“Mitigation strategies can be scaled up or down depending on the evolving local situation.”

• Let the people take charge

“Emphasize individual responsibility for implementing recommended personal-level actions” and “Empower businesses, schools, and community organizations to implement recommended actions”

• Protect the vulnerable

“…particularly in ways that protect persons at increased risk of severe illness” and “Focus on settings that provide critical infrastructure or services to individuals at increased risk of severe illness”

• Consider the costs

“Minimize disruptions to daily life to the extent possible”

By golly, I think CDC got the values right. I would add one more guiding principle of my own:

• Allow expression of individual risk tolerance

Give individuals the freedom to make choices to the extent that such choices do not cause harm to the community.

Local variation

The absence of a national US program to cope with the pandemic has caused problems, but for better or worse, it has allowed a lot of local variation in our mitigation strategies. I would argue that is a good thing, because the American states differ so greatly from one another that a one-size-fits-all wouldn’t fit most.

Part of the fit has to do with local culture. People in some states put a higher value on their freedom than their safety; others will want to contain the virus at higher cost. Demographics and epidemic biology also vary from place to place. For example, a new report highlights the importance of population density. Not only does crowding increase spread of the virus as you would expect, it may also increase the overall death rate. A possible explanation is that being exposed to multiple people with the virus gives you a higher initial inoculation, and can make you get sicker. Bottom line: big cities will need to reopen more cautiously than small towns.

In a state as large and diverse as my own (California), this variation goes down to the county level, so I think {OPINION} the governor should devolve more decision-making about re-opening to the counties. Let the locals determine their own fate. Advantages? This is consistent with the American values of federalism and self-determination. This permits experimentation to learn what works in managing the pandemic. Disadvantages? I see a potential problem with the consequences of one county’s decisions spilling over into other counties, in the form of a local spike in cases. I think it’s worth the risk, because of principle #2 (flexibility—change course). Unless it’s in a major population center, a bad outcome in one county won’t impact the big picture because we already have community circulation of the virus everywhere.

We have local variation on a global scale, too. Different nations have chosen different approaches to mitigation. Books will be written about how South Korea, and China, and Singapore, and Brazil, and Italy, and Great Britain, acted in different ways with different long-term outcomes that we have yet to see. Here, I’d like to mention Sweden.

The Swedish experiment

Sweden, a country of 10 million people, did not go on lockdown. Children under age 16 stayed in school, restaurants stayed open. Anders Tegnell, Sweden’s answer to our Dr. Fauci, talks about his country’s contrarian strategy in this interview. According to Tegnell, Sweden’s math models of the epidemic predicted less-alarming outcomes than the British Imperial College study that drove the Trump and Johnson administrations in the US and Britain toward lockdown in mid-March. Because of those models, and a legal framework that Tegnell says does not give the Swedish government authority to close down cities, Sweden has relied on less strict, voluntary social distancing measures. Swedes were asked to work from home, wash their hands, and avoid non-essential travel. Gatherings over 50 people were banned, high schools and universities were closed, and people over age 70 or otherwise at greater risk were asked to self-isolate. Visitors were banned from senior care homes.

Here is what Dr. Tegnell says:

“I think it has been overstated how unique the approach is. As in many other countries, we aim to flatten the curve, slowing down the spread as much as possible — otherwise the health-care system and society are at risk of collapse.

This is not a disease that can be stopped or eradicated, at least until a working vaccine is produced. We have to find long-term solutions that keep the distribution of infections at a decent level.”

Sweden succeeded. They may have reached their peak this week, and their health care system still has room for more patients. This, while living in a way that is sustainable for many months at much less cost to the economy than in countries with lockdown policies.

The “victory” hasn’t been total. Sweden has “higher death rates in relation to its population size than anywhere else in Scandinavia” (BBC News). Would those deaths have been prevented by a national lockdown? It’s hard to say. 50% of them were in elderly care homes, where visitors were banned anyway. Possibly some of the deaths could have been delayed. But because this strategy allows for more asymptomatic or mild infections, Sweden may have a higher herd immunity to protect them from a second peak. Tegnell argues that while Sweden might have more infections in the short term, it will not face the risk of an infection spike like other countries will have when they come out of lockdown.

Other guiding principles

Getting back to my summary of the principles that should guide mitigation and re-opening…

Flexibility is pretty obvious. Everyone, but especially politicians, should be free to change plans. We are making this up as we go. We should eagerly incorporate new data or fresh ideas, and change our approach when needed.

Letting the people take charge of the details of implementation is similar to the principle of local control. No one knows better how to manage social distancing inside a small business than the small business owner does. We should help organizations figure out how to implement; government shouldn’t tell them how to do it. In my opinion this is a particular concern here in California, where the state has an insatiable appetite for regulatory micromanagement.

Protect the vulnerable: My proposed strategy to foster herd immunity among those least at risk, and any re-opening, must protect those most vulnerable to infection. Herd immunity itself generates protection in the long term. In the short term, we have more data than ever to identify who is at highest risk of dying from COVID-19.

Consider the costs: The elephant in the room. In my posts I have said little about the tremendous financial and other costs of our current mitigation strategy, but this is not a mere detail. Any risk of loosening social distancing must be measured against the cost of lockdown.

Individual risk tolerance: In my opinion, any re-opening plan should make every effort to reasonably accommodate individuals who wish to make choices that some consider risky. We all have a different personal tolerance for risk, and a different measure of the personal benefit of, say, re-opening our small business, or going to the beach. Allowances should be made out of respect for the right of the individual to self-determination. If this kind of freedom isn’t built in to the plan, a growing number of people will take it anyway because of “behavioral fatigue” or financial distress.

The challenge is to do this in a way such that any consequence of individual behavior falls on the individual, and not the community. I think it’s possible, and in my next post, I’ll tie all of this together in the context of a critique of California Governor Newsom’s new pandemic roadmap.

Coronavirus Endgame PART 5: A plan to relax social distancing {coming soon}

Amy Rogers, MD, PhD, is a Harvard-educated scientist, novelist, journalist, and educator. Learn more about Amy’s science thriller novels, or download a free ebook on the scientific backstory of SARS-CoV-2 and emerging infections, at AmyRogers.com.

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