Many people have said many things about SARS-CoV2. And many of those things have been wrong. I doubt there is a not a person alive who has not been wrong about something. I am not afraid of being wrong, so I have at times been vocal about my thoughts on the virus, even sometimes speaking ahead of the evidence when I saw a pattern emerging.
I will lead with something I got wrong: I thought weather would have more of an effect than it does. In my defense, at the time I thought this, I had been convinced by the consensus belief that the virus spreads mainly through surface contamination. Given the studies that demonstrated the effect of temperature and humidity on the survival of the virus on surfaces, I expected that hot weather would have a dramatic effect on how much surface contamination was occurring. Of course, we are now fairly confident that the main mechanism of spread is close contact with the air around an infected person. Surface contamination appears to play a minor role (if any at all – it’s not clear to me).
The irony in basing my theory about weather on the belief in surface contamination is that I was right about how the virus was spreading from the beginning. I very early on expressed my belief that the virus was in the air. I thought this explained the disasters in Wuhan and Italy – neither place was maintaining any kind of infection control protocols at first, allowing infected patients to intermingle with other patients, lying in hallways, and so on. But the insistence that the virus was not in the air was so strong and backed by so many expert voices that I backed off in my belief about the virus traveling through the air. This led to my wrong belief that weather would have a major impact (weather clearly has some impact – and probably delayed major outbreaks in California and the US South for months).
Getting to the meat of this argument, I have analyzed a lot of information from many countries all over the world and have drawn some conclusions about how this virus works and in particular how the outbreaks work and the measures to control it. I may be wrong – there may be something I am missing that provides an alternative explanation. I have been wrong before. If I am wrong, I would be thankful if someone shows me how I am wrong.
Without further delay, here it goes.
The virus appears to have two potential phases of outbreak:
Phase 1: Whack-A-Mole
Phase 2: You Are Screwed
The Whack-A-Mole phase occurs when the virus first arrives in a country’s borders. Testing, tracing, and isolation (TTI) of contacts is the Whack-A-Mole game. After examining many countries around the world, I have come to the conclusion that TTI is *highly* effective. Countries all over Asia, Australia & New Zealand, half of Europe, and even the US state of Hawaii, have proven that you can keep the virus at bay by identifying outbreaks and isolating those exposed.
More on this later, but there appears to be a divide on how countries are playing Whack-A-Mole. The EU countries and Australia & New Zealand have convinced themselves that lockdowns are a necessary part of this game, while the Asian countries have largely ignored lockdowns, realizing that Whack-A-Mole is effective without them.
You Are Screwed
This phase begins when community spread in your country reaches a level that overwhelms your manpower to perform TTI. There are too many moles and not enough whackers. When you reach this phase: YOU ARE SCREWED. Contrary to conventional wisdom, I have seen *no* evidence that any of the extreme measures taken in many countries have actually stopped the virus from spreading once community transmission is high. NOTE: The United States deserves special credit here for cancelling the Whack-A-Mole phase and proceeding straight to the You Are Screwed phase. You cannot play Whack-A-Mole without tests.
These two phases can be seen across the world. Just honing in on Europe, there is a split between the countries. Half the major Western European countries successfully played Whack-A-Mole. The other half failed. The result is clear: the half that succeeded have little or no excess mortality. The half that failed have high to very high excess mortality. Australia and New Zealand succeeded in Whack-A-Mole. Both of them mostly kept the virus out and isolated, which made their game easy to play. Some of this is good execution on their part, and some is geographic isolation that minimized exposure before everyone knew what was going on. In Asia, Taiwan mostly kept the virus out. Other countries, like South Korea and Japan, played Whack-A-Mole successfully. South Korea perhaps played the most Whack-A-Mole. They had serious outbreaks early on that threatened to overwhelm them. But they also had a good system in place from past experience and they were eventually able to Whack enough moles to contain the virus.
A lot of different containment measures have been used, and in a lot of different circumstances. Basic measures, like banning large gatherings, encouraging working from home, and encouraging social distancing, were adopted by virtually everyone. Beyond that, the variety of interventions is quite wide. Asian countries mainly went for universal masking with some level of shutting down schools for older children (high school, college). Most avoided stay at home orders and the general shutting down in Europe. Some of them, like Thailand and India, went for a full shut down. In Europe, the measures were much more uniform. Nearly every major Western European country went for some sort of full shut down, often including restaurants, schools, and stay at home orders. Sweden is the famous outlier here, opting instead to let the virus run its natural course with only basic measures enacted. More on Sweden later. In Europe and the Americas, masking was discouraged at first, then an about face was made and masking was encouraged or required in many places. In the United States, measures varied widely by state, but most states eventually shut down and issued stay at home orders at some point.
Based on an analysis of data from all of these countries, I have come to the below conclusions about each intervention.
Testing, Tracing, and Isolation
The Big Kahuna. TTI clearly works. In fact, TTI appears to work phenomenally – far beyond expectations. Why? Probably because of the strange clustered way this virus spreads. It seems that so many carriers and situations result in little or no spread, but certain situations result in large clusters. If you can find those clusters and isolate everyone before they begin creating more clusters, you cut off the lifeblood of the virus. It seems like a daunting task, but is apparently not so daunting due to the dynamics of this virus’s spread.
Across the world, there is only one commonality between the countries that managed to keep the virus out – they all successfully played Whack-A-Mole. Some of them locked down. Some of them closed schools. Some just wore masks. There is wide variation in the measures adopted in each of these countries. But the intervention they share in common is TTI.
Has anyone noticed that virtually all of Asia has opened back up (if they shut down at all) and has the virus under control? This is testing, tracing, and isolation. Japan was called “the next disaster” by those who argued for stay at home orders. It never happened. You can find quite a few articles talking about the “Japanese miracle” – how they took very little measures – other than telling people to wear masks, avoid the 3 C’s, and…tested, traced, and isolated cases. Or, as Japan refers to it – breaking up clusters of infections. Japanese tracers went to work quickly and they are the reason Japan has succeeded. They are the reason all of Asia has succeeded.
Speaking of Asia, everyone remembers where this outbreak started, right? China has opened back up and even had several new pockets of infections. Do they appear scared? Do they appear on the verge of shutting anything back down? No, because they understand they have the tools to stop the virus. If you are vigilant, you can stop it before it gets out of control. They learned that.
If you want the ultimate example of the power of TTI, look no further than the Dharavi slum in Mumbai. As the city around it burned with infections, Dharavi remained relatively unscathed. With one million people in a 2.5 km2 area and people sharing public toilets, this is the last place you would want to be during a pandemic. And yet, Dharavi has been modestly successful. How? Stay at home orders are a fantasy. Social distancing is a fantasy. They succeeded because local doctors organized the world’s most dedicated grassroots testing, tracing, and isolation program. They went door to door testing and locating sick people. And it worked. It may not work forever – they have to remain ever vigilant and never let up – and that is difficult with infections all around you and such cramped conditions. But if you want to see how successful Whack-A-Mole can be, just know that you can even play this game in Dharavi.
The basic measures like cancelling large events and working from home are probably highly effective, but it’s difficult to say for sure because everyone enacted them. But we know from the study of “super spreading” events that these measures decrease the number of those potential events. Case studies from South Korea show how widely the virus can spread in an office environment, so working from home is likely a key intervention. There are many case studies of large gatherings where the virus spread widely, so again it’s clear cancelling these events is important.
Stay at Home Orders
Now I will make almost everyone angry. I see no evidence that stay at home orders were very effective. Belief in stay at home orders has become a religious test. I think partly this is due to the large consensus that formed around stay at home orders in the scientific community (without evidence) and the opposition to such orders by Trump and Trump followers. Together, this has created an instinctive response from many people that immediately accuses anyone who challenges stay at home orders of being “crazy” or a “flat Earther”. Ironically, belief in stay at home orders is the ultimate flat Earth mentality because it demonstrates an inability to properly read data and critically think about that data. For most, it probably just represents political ideology and parroting consensus.
Why does it look like stay at home orders are not that effective?
First, what happened to the spike in cases that was supposed to happen in Europe when countries began rolling back their measures? It did not happen. I have not heard a plausible explanation for this – I saw some articles saying “hmmmm” and then everyone moved on. But this is a big red flag. Because the most plausible explanation for this is that 1) these places reached herd immunity, and 2) the measures enacted were not that effective, so unraveling them did not result in the expected spike in cases. I have seen no other plausible explanation. Some might argue that masks picked up the slack for these measures. That is not the case based on the data, and if it were, it would still mean that masks could have been worn instead of stay at home orders, which carried a heavy burden. Either way, stay at home orders look like a huge mistake.
Second, many Asian countries do not have stay at home orders and are doing just fine. They do not seem to need stay at home orders to control the virus, so why does everyone assume stay at home orders are a key to the strategy that kept it out of other countries?
Third, when the Financial Times analyzed lockdowns, they found they only work if they were “done early”. This should be a huge red flag. Why? Well, what is the logical explanation for why a lockdown would work “early” but not later? I have not heard one. Such a reason exists for TTI – there are manpower limitations. If the spread overwhelms the manpower, it fails. That makes sense. But I cannot make sense of this idea of lockdowns working early but not late. It does not sound plausible to me.
Instead, lockdowns appear to be the ultimate mistake of seeing correlation and assuming causation. Success in Europe gave rise to assumptions that the most controversial and most hotly contested measures worked. There is enormous pressure to validate lockdowns, given their massive cost. But lockdowns are merely along for the ride. The reason lockdowns “work” early and not late is that what is really working is Whack-A-Mole – TTI. Lockdowns might make it a little easier to play Whack-A-Mole, but the data seems to indicate they do not do a whole lot. My reading of the data indicates that lockdowns “worked” if used early because TTI works. And when used late lockdowns “stopped” the outbreaks because they were issued in the weeks before reaching herd immunity. Lockdowns are merely a spurious correlation of TTI in the early phases and a spurious correlation with herd immunity in late outbreaks.
I live in the state of Illinois, and when we came out of our lockdowns, we saw very little bump in cases. We have now opened restaurants and bars and seen a small bump up in cases. Nothing Earth shattering – or on any scale that justifies lockdowns.
Fourth, lockdowns clearly failed in many places, but no one wants to talk about it. In Illinois, lockdowns were issued fairly early. But the peak of the virus occurred *8 weeks* after the lockdown started. That’s way too long to make any sense. In other countries, such as India or Peru, lockdowns failed completely. Why? Because they failed *everywhere*. But India and Peru lack the resources to effectively contact trace. And Illinois does not lack those resources, but lacked the tests necessary to do it (lack of tests was truly the original sin in the United States).
Side notes relating to contact tracing: the Indian city of Bangalore seems to have done much better than Delhi or Mumbai so far. I read an article that said Bangalore had traced 47 contacts for every positive test and Delhi had only traced 1 contact for every positive test. The results in each city follow from that. Canada is also an interesting case. Quebec was hit hard, but Toronto appears relatively unscathed. I wondered why, and was unsurprised when I found an article talking about Toronto’s contact tracing program and experience from SARS.
What is strange about stay at home orders is they were originally promoted as “flattening the curve”. They appear to have done this – albeit modestly. The chart of deaths in the state of Illinois looks flatter/smoother than a chart of Sweden. But somewhere along the line we began pretending we could stop the virus. We talked about “the hammer and the dance”. But it turns out the hammer was made of glass. I am not sure why this was invented – was it because the models that projected massive deaths were proving to be wrong, so we needed a new justification for these drastic interventions? Did we realize 2.2 million people in the US were *not* going to die, so we decided to shift the justification for stay at home orders to stopping the virus in its tracks – a proposition with no historical support?
Closing Indoor Seating in Restaurants and Bars (and churches)
It is likely this has a moderate effect. We have seen super spreading cases in restaurants, bars, and churches. When Illinois opened these things back up, there was a modest increase in cases. There is not much to say about this – other than they are precisely the kind of situation we know can spread the virus.
There is no evidence this did much. Many Asian countries had data from the original SARS that said closing schools did not help. Based on this data, they kept them open and there were no major problems. Sweden kept their schools open below high school age for this same reason. They do not seem to have had major problems. Several studies from different countries (Ireland, France, Australia) find little evidence of any kind of spread in schools. The R0 value in a school environment appears to be below 1.0 – quite a bit below, possibly. Given the data, closing schools was a mistake. Some scientists in Norway have already owned this mistake and said they would not do it again.
I believe the evidence indicates that mask wearing is highly effective for protecting yourself and those around you in most situations. At first I thought mask wearing might actually bring transmission below 1.0. After the data started coming in, I changed my stance. I do not see any evidence that masks can stop the virus. Masks probably fail for similar reasons that lockdowns fail: the people and situations that are at high risk of infection are not amenable to mask wearing. Perhaps over an 8 hour work shift, wearing a mask does not make much difference because virus will still make it outside the masks of those infected, circulate in the air, then back into the air breathed in by others, even through their masks. I am not really sure all the dynamics, but I am fairly confident from the data that masks are not a panacea. In the United States, lots of places are wearing masks. But only those places that had major early outbreaks are seeing infections fall while wearing masks. It is much more likely those places have some degree of herd immunity, which is the main reason infections are falling, not masks. If you lack herd immunity, masks do not stop the virus from spreading.
Another way to tell: ask yourself if any Asian country would be willing to shut down their contact tracing programs and rely solely on masks. Not a chance. The reverse is probably also true, but not to the same degree. If they had to drop one of the two, it would be masks. If people were only wearing masks in those countries with no contact tracing, I have no doubt that infections would begin to grow again.
The problem with all the interventions above (aside from TTI), are that I have seen no evidence that *any* combination of them has brought transmission down below 1.0 *anywhere*. The evidence is just not there. Thus, they are just flattening the curve. If that is the case, then you will eventually move toward herd immunity.
As demonstrated by a couple papers out recently, herd immunity is likely much lower than we think. Marc Lipsitch discussed these papers here: https://twitter.com/mlipsitch/status/1258827506930667523
The Gomes paper in particular is excellent, and it is a scandal that paper was rejected for political reasons.
From what I can see, every country in Europe that instituted lockdowns to “stop” major outbreaks did *not* succeed. They reached herd immunity and began to decline.
Sweden as Myth Slayer
I got a feeling very early on that one reason the attacks on Sweden were so aggressive and toxic was that Sweden was in a position to serve as a control for extreme lockdown measures taken elsewhere in Europe. If the Swedes only took basic measures and came out in a similar place as everyone else, it would undermine the case for those extreme measures. Reading media coverage of Sweden, one would get the impression that Anders Tegnell is worse than Donald Trump. Ironically, I believe Sweden is the only Western country where the outbreak response was guided 100% by scientists, with no political interference. Sweden, who up until this outbreak has been a darling of the American Left, and who has a structure that gives full control to their scientists, somehow became the most hated player. Could it be that – like many outside science noted, such as Glenn Greenwald – that our scientists and science have become politicized?
I am not going to go into detail analyzing Sweden’s outbreak and whether they have reached herd immunity because that was done here: https://www.nicholaslewis.org/the-progress-of-the-covid-19-epidemic-in-sweden-an-analysis/.
In summary of that analysis: 1) Stockholm reached herd immunity in late April, 2) Deaths have clearly declined due to that herd immunity, 3) the rest of the country is behind Stockholm, but getting there, and 4) Deaths have declined even more dramatically than infections because most of the elderly, vulnerable people in nursing homes have been exposed and either recovered or died. The newer batch of infections is younger and healthier.
This pattern of infections late in the outbreak having a lower death rate has repeated everywhere that I have seen – with Italian doctors puzzling over why the virus seems so tame now. It’s not the virus – it’s the people being infected. They are less vulnerable and less likely to have a serious infection.
If you accept the reality staring us in the face that Sweden reached herd immunity in Stockholm, a lot of funny things about the virus that do not make sense suddenly make sense. It now makes sense that European countries coming out of lockdowns saw little increase in cases. It now makes sense that European countries that took lots of different measures had similar experiences and similar mortality rates. It now makes sense that lockdowns “worked early” and not late because it was not the lockdowns working late – or early. So many dominoes fall into place that it becomes an example of Occam’s Razor. The simplest explanation is indeed right: herd immunity was reached in those places with major outbreaks.
Are Asian Countries Doing it Right?
We are quite sure that wearing a mask substantially decreases the amount of virus an infected person will project into the air around them. We are also fairly certain that masks protect a person from infection – to some degree. Asian countries tend to have a culture of mask wearing when they are sick and they are wearing masks right now. We also have evidence that some people with asymptomatic infections or minimal exposure develop a robust T-Cell immune response. Is opening society and behaving normally, while wearing masks, actually the most effective thing we can do? Does wearing a mask increase the proportion of people who will have minimal exposure to the virus and develop only a T-Cell immune response? Is the best process actually one that has people go about their business while wearing a mask to minimize their risk, while either using contact tracing to keep infections down or pursuing herd immunity if they are already too high? I don’t know the answer to this, but it’s an interesting question.