Resisting Covid - Part 1

This is part 1 of a 3 part series reflecting on Covid and civil society. This first part considers how governments handled the pandemic, and how they should have handled it. The second part will concern the relationship between individuals and their governments, and the final part will examine why these problems of coordination exist and how we might solve them. Much of the science of the Covid responses, especially the efficiency of various interventions, is still being examined so I have tried to be general, but it is possible that some of my conclusions will prove faulty.

Since the Covid-19 Pandemic began, somewhere around 20 million people have died of the disease. Assuming no radical changes in human behavior, that number will continue to slowly rise until humanity develops better resistance or the slow rise becomes master due to viral mutations. It is an incredible catastrophe in the history of humanity, and one can only hope that it will continue to be unique.

But that is best left as a hope. The underlying conditions which produced this pandemic are relatively unchanged. Novel pathogens continue to spawn and vast networks of communication and transmission do not have effective safeguards. If Covid comes again, we will probably do better, but we will not beat it. If Covid comes again, but is far more deadly and far more communicable (which are not outside of biological possibility), the resulting destruction could be immense, even existential.

Covid was resisted in various ways by every society on earth, and it is worth examining how they resisted, whether they could resist a worse pandemic, and whether they would.

What Covid Means

There have been many pandemics throughout history. Covid is hardly unique for its death toll, cultural impact, or place in history. Bubonic plague killed far more in its spread through Medieval Eurasian trade networks and both the Spanish Flu and AIDs are earlier examples of truly modern global pandemics.

Pandemics are created by a combination of a rare biological occurrence of a virus (for most purposes entirely random) with the networked behavior of human civilization. If an extremely deadly virus infects a small isolated tribe, it does not make a pandemic; if a human society lives in extremely poor hygiene and socializes with actions that transmit disease, but there is no deadly virus, they will be fine. However once a pandemic begins, it is a biological process which humans have little hope of stopping.

Quarantine, isolation, cures will all be tried and may reduce death tolls significantly, but they have not halted pandemics, and the traditional human response has been to simply let them happen. In most premodern societies, public health was not a governmental responsibility but a religious one: plagues were sent as punishments for impiety, whether against Oedipus or a son of Heaven who has lost his mandate. History features some coordinated action - the early Christians distinguished themselves by tending to the sick (at great peril and great losses) and burying the corpses left on the streets - but such struggles were small and rarely at the level of large government. Justinian, one of the most competent and active emperors of his time, could do little against the plague other than pray and fight for his own survival, and it would weaken his empire for centuries before it simply went away due to some biological mechanism beyond understanding.

By the time of global pandemics and modern medicine we had more hope of response but little result. The Spanish Flu was fought by local societies and government recommendation, but there was no confidence that it could be beaten and had very little world coordination due to WWI. AIDS, strange for its slow gestation and limited but polarizing transmission, after decades unchecked was slowed and shows signs of stopping thanks to a combination of pharmaceutical research and actual coordinated policy.

What distinguishes Covid from these other pandemics is that was resisted with far more effort, far more coordination, and far more success than any previous pandemic, even though that success was limited and disappointing. Within weeks of its spread, the vast majority of governments were taking direct and drastic action which had never before been tried and on scales never before imagined. The full force of the contemporary centralized state was turned against the pandemic, aided by all that modern medicine could summon. Covid was certainly in some sense created by modernity - the network of air travel and dense spaces allowed it to go worldwide within months, its original generation aided most likely by an industrialized contact with wild disease-bearing animals - but there was a hope that modernity would also be able to resist it.

The results were mixed. Covid is one of the deadliest pandemics in human history, but it could have been far worse. It is extremely hard to estimate the global effects of prevention, especially since the virus is still endemic, but it seems to reasonable to estimate that without the combined effects of government regulation (lockdowns, border closures, mask policy, etc) and mass-vaccination programs and medication, 10-20 million who would have died still live. It is perhaps the best coordinated resistance to a pandemic ever. In terms of a first effort it is not bad if the issues are solvable, but saving 50% of potential victims against a not-very-deadly virus that still majorly disrupted human civilization is not a full win either.

What We Did

The governments and societies of the world took different approaches to the pandemic, and their efforts do seem to have made a significant difference in the death they suffered. Among countries with reliable data, sizable elderly populations, and empowered governments Europe, the United States, and South America have done fairly poorly, whereas Japan, Taiwan, South Korea, Australia, and New Zealand have emerged relatively strongly. China is a special case.

The first method that every country tried was isolation, all grouped under the name of “lockdowns” but very different in details. Some closed borders, some forced people into their homes using state violence, some imposed tailored requirements based on monitoring of contagion, others simply made suggestions without enforcement. Of these, closing national borders was the most effective, especially on islands, followed by monitoring and strict enforcement of isolation. Lax suggestions without cooperation did little to restrict actual movement and spread, although it is crucial to remember that even in countries with little enforcement, many citizens voluntarily quarantined.

After this first period of isolation came masks which were effective, but never absolutely so. And along with these a suite of containment methods and practices which through ignorance willful or not did nothing. Disinfectants, the closing of outdoor spaces, and reminders that hand-washing was most important were all characteristic of the early response to the pandemic and lasted far beyond reasonable opinion as to their effectiveness. Even after supply issues with medical-grade masks were solved, public messaging did not change to reflect that these were far more effective than cloth masks.

A particularly frustrating quality of early pandemic interventions was their basis in the droplet theory of diseases. This theory, known well by the public health community, was the scientific basis for most of the original recommendations about Covid. It appears that not only was it wrong, but it was actually a decades-old mistake, a misunderstanding laundered through the knowledge systems of public health - generations of textbooks, lectures, and articles - until it ended up killing so many thousands needlessly. Amid a sea of evidence (evidence that was dying at alarming rates) that Covid was airborne, much of the establishment closed ranks and never explicitly admitted the revelation. No follow-ups to investigate what other beloved facts are false seems to have taken place.

Non-pharmaceutical interventions came with societal costs and a variety of societal reactions. The decision to close down schools and carry on education remotely in the United States now appears to have had devastating effects on the learning of children while there is serious reason to doubt it significantly halted the spread of Covid. The virus was consistently being spread by adults in closed indoor environments (which were never shut-down more frequently than schools) and passed onto their children in the closed indoor environment of their homes. This drastic and costly decision was in many places quite popular with parents and children alike. Masks on the other hand were met with strong resistance in many communities, although the cost to wearing them was minuscule. Countries which performed real and serious contact tracing seem to have done so with significant citizen buy-in or strictly imposed mandates.

In a repeat scenario, amid the constant uncertainty as to the nature and evolution of the virus, it seems that total border closure such as that of Australia and New Zealand is the first step towards fighting off the virus. The public health authorities initial reaction to stick to accepted facts by insisting on droplet spread and the non-necessity of masks was a waste of human life in order to maintain authority and avoid panic, all reasonable precautions should be taken immediately. Contact tracing should be done in a real and effective way, with South Korea as a good model. The more serious actions with significant trade-offs - shutting down businesses, schools, imposing regional isolations, etc - are inherently more difficult and have to be decided based on the actual severity and transmissibility of the virus, as well as the network effects which may make total eradication unfeasible. The successful governments did these things, although none implemented it perfectly.

What We Did with Drugs

NPIs were only the first phase of fighting the virus, a delay tactic. The debut of the vaccines in November 2020 and the development of anti-viral medication the following year was an incredible fruit of our advanced scientific civilization. It remains hard to estimate the relative effects of different interventions, especially since counterfactuals are involved, but my bet currently would be that the vaccines deserve most of the credit for saving lives from the pandemic. Those governments who supported rapid vaccine development deserve praise for it and in retrospect the potential for these vaccines was greatly underestimated.

Less effective was how the governments and other authorities made use of the vaccines that were developed. While willing to use unprecedented and drastic measures to contain the virus in the first months, in nearly every country a strong line was drawn at procedure around these pharmaceutical interventions.

The normal process for drug approval was followed albeit at an accelerated pace, there were meetings and tests and waiting periods. The vaccines were ready in March, tested through November, and manufactured and distributed from December on. Distribution of vaccines was handled with some concern, but not concern appropriate to the lives that were lost to waiting. In early 2021, we should have had about 10 times more vaccines available than we did. Europe’s price negotiation which delayed vaccine deployment by months, a human disaster, has not been met with any correction. The decisions by Russia, China, and others to prefer vaccines which were produced internally but ineffective for nationalist reasons, condemning thousands to needless death, have not received serious scrutiny by their citizenry.

After the first round of vaccines, mandates were considered and implemented to differing degrees. Much of Western Europe did implement vaccine passes which seem quite effective at driving rates up. In the United States, mandates were accepted by many, but fought tooth and nail by others. The US government put up a fight on this initially but happily folded after a Supreme Court decision. The resistance movement to vaccines was treated by state authorities as a respectable belief that must be tolerated, despite in the process accruing a far higher body count than any terrorist ideology yet devised. After the death toll fell below a certain threshold, nearly all mandate requirements were relaxed, even if excess deaths continue to be greatly elevated above 2019 levels.

While millions of lives were saved thanks to vaccines, millions more certainly could have been saved if we had done them better. On this there has mostly been silence. No government has considered it urgent to reexamine their medical bureaucracy. The tacit message to all is that things went acceptably.

While early non-vaccine drugs sometimes became popular as potential saviors against the virus, the release of Paxlovid seems to have come too late for general enthusiasm. Governments promoted the drug, but not very much. Positive benefits of Fluvoxamine were mostly ignored because it was not the use of the drug intended by the bureaucracy and it never caught on like other miracle drugs which had brief moments of social media popularity.

Vaccines and drugs were key to reducing death. Many states put their resources into them, many did not. But when one considers purely the economic loss that comes from preventable death, no state seems to have even put that kind of resources into their pharmaceutical policy. Even if human life has no independent value, the efforts here were inadequate. And since human life has incalculable value, this was a monstrous tragedy.

What we Never Considered

Covid was remarkable in that every society employed novel methods of prevention and containment while also avoiding particular methods of prevention and containment that were widely discussed and had reasonable chance of saving a substantial number of people.

NPIs received a significant amount of creative attention, with many governments and individual people trying some methods that worked and many that didn’t, an experimental drive that was warranted by the crisis. There is little that wasn’t tried. I can speculate that mass production of masks superior to N95s was under researched, or that specific monitoring programs targeted at the disproportionately-at-risk elderly population should have been tried, but these are only guesses.

On the pharmaceutical side, there is much more. Human challenge trials, in which willing test-subjects volunteer to infect themselves in order to test vaccine efficacy, seem to have never been seriously considered. Releasing the vaccines in March 2020, which were complete and scientifically sound on first principles, but untested, seems to have never been seriously considered. Massively investing in vaccine production to an extent that would involve producing many wasted doses on failed candidate vaccines, but would still pay off for the death it would prevent, seems to have never seriously been considered. All of these potential interventions were discussed openly, but totally ignored by those with the power to implement them. We now know each of these would have saved at least hundreds of thousands of lives, possibly millions, but greatly speeding up the vaccine timeline. This possibility must be weighed against the various possibilities that the vaccines under consideration would have been ineffective or actually harmful, but such a calculation was never seriously considered. Hundreds of elderly people faced almost certain death from mass infection events while within miles of a vaccine candidate that they were not allowed to have because there was a chance it could harm them.

Also not considered was coordination between nations, perhaps allowing for total eradication of the virus. After escaping from Wuhan, it seemed inevitable that Covid would spread around the world, but was that truly inevitable? Could actual strict lockdowns and monitoring, especially along standard national lines, have led to a future where the virus is not endemic, but gone? It seems possible. But it is also striking that no coordination seems to have happened at all.

If there were a potential alien invasion that would kill 20 million elderly people and then leave, it would be my hope that the governments of the world would put aside their differences and work together to combat this evil. Nothing of the sort. The WHO, the closest we had to such a special forms agency, quickly understood its job to be providing generic guidelines and managing publicity for its clients.

It is especially shameful that vaccine and drug development seems to have come out of the existing international pharmaceutical system with very little sense of urgency from the stewards of humanity. Using European science, the United States led the way on new mRNA vaccine development, while a smattering of other countries with existing infrastructure followed with their own efforts. Some of these vaccines worked decently, some did not at all. If the U.S. had not made such vaccines, or had not wanted to share, or refused to approve them due to its horrible bureaucracy, where would the world have been? Vaccines saved the world, and very few countries seem to have considered it proper to invest in vaccine technology. Antivirals are much the same.

The Ideal Plan for the State

Assuming that Covid was unavoidably going to become endemic, the best plan for a state responding to the pandemic was as follows:

1. Upon first reports of a possible deadly pandemic, close all borders. Allow those outside to enter the country only with strict quarantining and monitoring.

2. Isolate infections with enforced quarantines.

3. Urge wearing of effective N95-equivalent masks in all indoor environments as a low-cost intervention. Communicate honestly. Do not lie in order to avoid panic.

4. Conduct as much of life as practical in outdoor and well-ventilated environments.

5. Do not allow clusters of the elderly, such as nursing homes, to become major infection sites through whatever means practical.

6. Invest in vaccine research and trials as soon as possible.

7. Experiment with medications, especially with low-risk profiles. Encourage fluvoxamine use as soon as it is discovered. It is better to encourage use of multiple drugs without significant negative outcomes but possible upside than to encourage none because positive upsides cannot be proven.

8. Begin mass production of all candidate vaccines with massive debt-funded government spending.

9. Distribute vaccines to acutely vulnerable even before trials conclude.

10. After trials, begin mass distribution of vaccines using the full force of government messaging and infrastructure networks.

11. Implement vaccine mandates for major indoor public spaces.

12. Restore in-person functions for crucial societal institutions (schools, infrastructure, etc) as soon as is safe, using cost benefit analysis based on the risks to the relevant populations. If kids need to do school outside in the winter, but it allows their education to continue, that may be worth it.

13. Export as many vaccines as possible, the economic benefits of allowing trading partners to function will more than pay for the costs.

No country did all this, but some came close. This strategy involves some compromises with individual liberty, but only some interventions would have been major. Even with strong limits on direct government interference with individual lives, this strategy would have saved many, although this question deserves more exploration.

Could we have saved everyone?

Even under the above strategy, many would have died. There seems to be a small portion of the very elderly, very weak population who will die from Covid even with the best vaccines and drug treatment currently available. Current Covid policy assumes that these people are essentially unsavable, and their options now are to isolate from an increasingly infectious disease or to risk it and possibly accept early death.

This cannot truly be called success. The best solution would be pharmaceutical guards against the virus which guarantee health and which can be distributed effectively, however this is largely a problem of medical science. The other solutions - strict enforced NPIs with no real endpoint until some pharmaceutical solution is developed or the virus mutates to some safe form - is impractical and certainly goes against the revealed preferences of the world population. People want to live without NPIs, even if that means accepting an elevated death rate for the elderly, just as they want to drive and allow unrestricted consumption of alcohol. But accepting these is in some ways accepting a failure.

China has tried a version of not accepting failure. There are many parts of China’s Covid response that have been bad, some merely inefficient and some cruel. The initial outbreak was allowed to spread, the deaths in Wuhan were kept hidden, the lockdowns brutal. The country has proven to be disastrously compromised when it came to vaccines, insisting on its own creations and prioritizing national prestige over human life, and has imposed many unnecessary and harmful restrictions forced on its people. But for the first years Chinese lockdowns allowed many to live mostly normally without the same specter of death as the rest of the world. If China’s Covid Zero policy ends and they suffer the same elderly death rates as Australia, New Zealand, Japan, and South Korea, the indefinite lockdowns that they are currently under will have largely been for nought, giving the elderly a few extra months by confining the general population. But if they come up with a new solution or the virus changes in their favor, this may be the ideal policy. I would not bet on this though.

Even among uncertainty, better things must be possible. These problems can be solved and the structures which prevent proper vigilance and action from governments can be changed.