Sure, don't hoard toilet paper – but if policymakers fear fear itself, they'll downplay real dangers to avoid "mass panic". Fear's not the problem, it's how we *channel* our fear. Fear gives us energy to deal with dangers now, and prepare for dangers later.
Honestly, we (Marcel, epidemiologist + Nicky, art/code) are worried. We bet you are, too! That's why we've channelled our fear into making these **playable simulations**, so that *you* can channel your fear into understanding:
This guide (published May 1st, 2020. click this footnote!→[^timestamp]) is meant to give you hope *and* fear. To beat COVID-19 **in a way that also protects our mental & financial health**, we need optimism to create plans, and pessimism to create backup plans. As Gladys Bronwyn Stern once said, *“The optimist invents the airplane and the pessimist the parachute.”*
[^timestamp]: These footnotes will have sources, links, or bonus commentary. Like this commentary!
**This guide was published on May 1st, 2020.** Many details will become outdated, but we're confident this guide will cover 95% of possible futures, and that Epidemiology 101 will remain forever useful.
So, let's make a very, *very* simple "epidemic flight simulator"! In this simulation, <iconi></icon> Infectious people can turn <icons></icon> Susceptible people into more <iconi></icon> Infectious people:
It's estimated that, *at the start* of a COVID-19 outbreak, the virus jumps from an <iconi></icon> to an <icons></icon> every 4 days, *on average*.[^serial_interval] (remember, there's a lot of variation)
[^serial_interval]: “The mean [serial] interval was 3.96 days (95% CI 3.53–4.39 days)”. [Du Z, Xu X, Wu Y, Wang L, Cowling BJ, Ancel Meyers L](https://wwwnc.cdc.gov/eid/article/26/6/20-0357_article) (Disclaimer: Early release articles are not considered as final versions)
If we simulate "double every 4 days" *and nothing else*, on a population starting with just 0.001% <spanclass="nowrap"><iconi></icon>,</span> what happens?
[^caveats]: **Remember: all these simulations are super simplified, for educational purposes.**
One simplification: When you tell this simulation "Infect 1 new person every X days", it's actually increasing # of infected by 1/X each day. Same for future settings in these simulations – "Recover every X days" is actually reducing # of infected by 1/X each day.
Those *aren't* exactly the same, but it's close enough, and for educational purposes it's less opaque than setting the transmission/recovery rates directly.
This is the **exponential growth curve.** Starts small, then explodes. "Oh it's just a flu" to "Oh right, flus don't create *mass graves in rich cities*".
But, this simulation is wrong. Exponential growth, thankfully, can't go on forever. One thing that stops a virus from spreading is if others *already* have the virus:
The more <spanclass="nowrap"><iconi></icon>s</span> there are, the faster <spanclass="nowrap"><icons></icon>s</span> become <spanclass="nowrap"><iconi></icon>s,</span>**but the fewer <span class="nowrap"><icon s></icon>s</span> there are, the *slower* <span class="nowrap"><icon s></icon>s</span> become <span class="nowrap"><icon i></icon>s.</span>**
But, this simulation is *still* wrong. We're missing the fact that <iconi></icon> Infectious people eventually stop being infectious, either by 1) recovering, 2) "recovering" with lung damage, or 3) dying.
For simplicity's sake, let's pretend that all <iconi></icon> Infectious people become <iconr></icon> Recovered. (Just remember that in reality, some are dead.) <spanclass="nowrap"><iconr></icon>s</span> can't be infected again, and let's pretend –*for now!*– that they stay immune for life.
With COVID-19, it's estimated you're <iconi></icon> Infectious for 10 days, *on average*.[^infectiousness] That means some folks will recover before 10 days, some after. **Here's what that looks like, with a simulation *starting* with 100% <span class="nowrap"><icon i></icon>:</span>**
[^infectiousness]: “The median communicable period \[...\] was 9.5 days.” [Hu, Z., Song, C., Xu, C. et al](https://link.springer.com/article/10.1007/s11427-020-1661-4) Yes, we know "median" is not the same as "average". For simplified educational purposes, close enough.
And *that's* where that famous curve comes from! It's not a bell curve, it's not even a "log-normal" curve. It has no name. But you've seen it a zillion times, and beseeched to flatten.
[^sir]: For more technical explanations of the SIR Model, see [the Institute for Disease Modeling](https://www.idmod.org/docs/hiv/model-sir.html#) and [Wikipedia](https://en.wikipedia.org/wiki/Compartmental_models_in_epidemiology#The_SIR_model)
**NOTE: The simulations that inform policy are way, *way* more sophisticated than this!** But the SIR Model can still explain the same general findings, even if missing the nuances.
Actually, let's add one more nuance: before an <icons></icon> becomes an <spanclass="nowrap"><iconi></icon>,</span> they first become <icone></icon> Exposed. This is when they have the virus but can't pass it on yet – infect*ed* but not yet infect*ious*.
(This variant is called the **SEIR Model**[^seir], where the "E" stands for <icone></icon> "Exposed". Note this *isn't* the everyday meaning of "exposed", when you may or may not have the virus. In this technical definition, "Exposed" means you definitely have it. Science terminology is bad.)
[^seir]: For more technical explanations of the SEIR Model, see [the Institute for Disease Modeling](https://www.idmod.org/docs/hiv/model-seir.html) and [Wikipedia](https://en.wikipedia.org/wiki/Compartmental_models_in_epidemiology#The_SEIR_model)
For COVID-19, it's estimated that you're <icone></icon> infected-but-not-yet-infectious for 3 days, *on average*.[^latent] What happens if we add that to the simulation?
[^latent]: “Assuming an incubation period distribution of mean 5.2 days from a separate study of early COVID-19 cases, we inferred that infectiousness started from 2.3 days (95% CI, 0.8–3.0 days) before symptom onset” (translation: Assuming symptoms start at 5 days, infectiousness starts 2 days before = Infectiousness starts at 3 days) [He, X., Lau, E.H.Y., Wu, P. et al.](https://www.nature.com/articles/s41591-020-0869-5)
Not much changes! How long you stay <icone></icon> Exposed changes the ratio of <spanclass="nowrap"><icone></icon>-to-<iconi></icon>,</span> and *when* current cases peak... but the *height* of that peak, and total cases in the end, stays the same.
**R<sub>0</sub>** (pronounced R-nought) is what R is *at the start of an outbreak, before immunity or interventions*. R<sub>0</sub> more closely reflects the power of the virus itself, but it still changes from place to place. For example, R<sub>0</sub> is higher in dense cities than sparse rural areas.
The R<sub>0</sub> for "the" seasonal flu is around 1.28[^r0_flu]. This means, at the *start* of a flu outbreak, each <iconi></icon> infects 1.28 others *on average.* (If it sounds weird that this isn't a whole number, remember that the "average" mom has 2.4 children. This doesn't mean there's half-children running about.)
[^r0_flu]: “The median R value for seasonal influenza was 1.28 (IQR: 1.19–1.37)” [Biggerstaff, M., Cauchemez, S., Reed, C. et al.](https://bmcinfectdis.biomedcentral.com/articles/10.1186/1471-2334-14-480)
The R<sub>0</sub> for COVID-19 is estimated to be around 2.2,[^r0_covid] though one *not-yet-finalized* study estimates it was 5.7(!) in Wuhan.[^r0_wuhan]
[^r0_covid]: “We estimated the basic reproduction number R0 of 2019-nCoV to be around 2.2 (90% high density interval: 1.4–3.8)” [Riou J, Althaus CL.](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7001239/)
[^r0_wuhan]: “we calculated a median R0 value of 5.7 (95% CI 3.8–8.9)” [Sanche S, Lin YT, Xu C, Romero-Severson E, Hengartner N, Ke R.](https://wwwnc.cdc.gov/eid/article/26/7/20-0282_article)
In our simulations –*at the start & on average*– an <iconi></icon> infects someone every 4 days, over 10 days. "4 days" goes into "10 days" two-and-a-half times. This means –*at the start & on average*– each <iconi></icon> infects 2.5 others. Therefore, R<sub>0</sub> = 2.5. (caveats:[^r0_caveats_sim])
[^r0_caveats_sim]: This is pretending that you're equally infectious all throughout your "infectious period". Again, simplifications for educational purposes.
But remember, the fewer <spanclass="nowrap"><icons></icon>s</span> there are, the *slower*<spanclass="nowrap"><icons></icon>s</span> become <spanclass="nowrap"><iconi></icon>s.</span> The *current* reproduction number (R) depends not just on the *basic* reproduction number (R<sub>0</sub>), but *also* on how many people are no longer <icons></icon> Susceptible. (For example, by recovering & getting natural immunity.)
When enough people have immunity, R <1,andthevirusiscontained!Thisiscalled**herd immunity**.Forflus,herdimmunityisachieved*with a vaccine*.Tryingtoachieve"naturalherdimmunity"bylettingfolksgetinfectedisa*terrible*idea.(Butnotforthereasonyoumaythink!We'llexplainlater.)
**NOTE: Total cases *does not stop* at herd immunity, but overshoots it!** And it crosses the threshold *exactly* when current cases peak. (This happens no matter how you change the settings – try it for yourself!)
This is because when there are more <spanclass="nowrap">non-<icons></icon>s</span> than the herd immunity threshold, you get R <1.AndwhenR<1,newcasesstopgrowing:apeak.
It's a paradox. COVID-19 is extremely contagious, yet to contain it, we "only" need to stop more than 60% of infections. 60%?! If that was a school grade, that's a D-. But if R<sub>0</sub> = 2.5, cutting that by 61% gives us R = 0.975, which is R <1,virusiscontained!(exactformula:[^exact_formula])
[^exact_formula]: Remember R = R<sub>0</sub> * the ratio of transmissions still allowed. Remember also that ratio of transmissions allowed = 1 - ratio of transmissions *stopped*.
Therefore, to get R <1,youneedtogetR<sub>0</sub> * TransmissionsAllowed <1.
(If you think R<sub>0</sub> or the other numbers in our simulations are too low/high, that's good you're challenging our assumptions! There'll be a "Sandbox Mode" at the end of this guide, where you can plug in your *own* numbers, and simulate what happens.)
*Every* COVID-19 intervention you've heard of – handwashing, social/physical distancing, lockdowns, self-isolation, contact tracing & quarantining, face masks, even "herd immunity" – they're *all* doing the same thing:
So now, let's use our "epidemic flight simulator" to figure this out: How can we get R <1inaway**that also protects our mental health *and* financial health?**
Around 1 in 20 people infected with COVID-19 need to go to an ICU (Intensive Care Unit).[^icu_covid] In a rich country like the USA, there's 1 ICU bed per 3400 people.[^icu_us] Therefore, the USA can handle 20 out of 3400 people being *simultaneously* infected – or, 0.6% of the population.
[^icu_covid]: ["Percentage of COVID-19 cases in the United States from February 12 to March 16, 2020 that required intensive care unit (ICU) admission, by age group"](https://www.statista.com/statistics/1105420/covid-icu-admission-rates-us-by-age-group/). Between 4.9% to 11.5% of *all* COVID-19 cases required ICU. Generously picking the lower range, that's 5% or 1 in 20. Note that this total is specific to the US's age structure, and will be higher in countries with older populations, lower in countries with younger populations.
[^icu_us]: “Number of ICU beds = 96,596”. From [the Society of Critical Care Medicine](https://sccm.org/Blog/March-2020/United-States-Resource-Availability-for-COVID-19) USA Population was 328,200,000 in 2019. 96,596 out of 328,200,000 = roughly 1 in 3400.
That's what [the March 16 Imperial College report](http://www.imperial.ac.uk/mrc-global-infectious-disease-analysis/covid-19/report-9-impact-of-npis-on-covid-19/) found: do nothing, and we run out of ICUs, with more than 80% of the population getting infected.
(remember: total cases *overshoots* herd immunity)
Even if only 0.5% of infected die – a generous assumption when there's no more ICUs – in a large country like the US, with 300 million people, 0.5% of 80% of 300 million = still 1.2 million dead... *IF we did nothing.*
(Lots of news & social media reported "80% will be infected" *without* "IF WE DO NOTHING". Fear was channelled into clicks, not understanding. *Sigh.*)
The "Flatten The Curve" plan was touted by every public health organization, while the United Kingdom's original "herd immunity" plan was universally booed. They were *the same plan.* The UK just communicated theirs poorly.[^yong]
[^yong]: “He says that the actual goal is the same as that of other countries: flatten the curve by staggering the onset of infections. As a consequence, the nation may achieve herd immunity; it’s a side effect, not an aim. [...] The government’s actual coronavirus action plan, available online, doesn’t mention herd immunity at all.”
From a [The Atlantic article by Ed Yong](https://www.theatlantic.com/health/archive/2020/03/coronavirus-pandemic-herd-immunity-uk-boris-johnson/608065/)
Increased handwashing cuts flus & colds in high-income countries by ~25%[^handwashing], while the city-wide lockdown in London cut close contacts by ~70%[^london]. So, let's assume handwashing can reduce R by *up to* 25%, and distancing can reduce R by *up to* 70%:
[^handwashing]: “All eight eligible studies reported that handwashing lowered risks of respiratory infection, with risk reductions ranging from 6% to 44% [pooled value 24% (95% CI 6–40%)].” We rounded up the pooled value to 25% in these simulations for simplicity. [Rabie, T. and Curtis, V.](https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-3156.2006.01568.x) Note: as this meta-analysis points out, the quality of studies for handwashing (at least in high-income countries) are awful.
[^london]: “We found a 73% reduction in the average daily number of contacts observed per participant. This would be sufficient to reduce R0 from a value from 2.6 before the lockdown to 0.62 (0.37 - 0.89) during the lockdown”. We rounded it down to 70% in these simulations for simplicity. [Jarvis and Zandvoort et al](https://cmmid.github.io/topics/covid19/comix-impact-of-physical-distance-measures-on-transmission-in-the-UK.html)
**Play with this calculator to see how % of <spanclass="nowrap">non-<icons></icon>,</span> handwashing, and distancing reduce R:** (this calculator visualizes their *relative* effects, which is why increasing one *looks* like it decreases the effect of the others.[^log_caveat])
Now, let's simulate what happens to a COVID-19 epidemic if, starting March 2020, we had increased handwashing but only *mild* physical distancing – so that R is lower, but still above 1:
1. This *reduces* total cases! **Even if you don't get R < 1, reducing R still saves lives, by reducing the 'overshoot' above herd immunity.** Lots of folks think "Flatten The Curve" spreads out cases without reducing the total. This is impossible in *any* Epidemiology 101 model. But because the news reported "80%+ will be infected" as inevitable, folks thought total cases will be the same no matter what. *Sigh.*
2. Due to the extra interventions, current cases peak *before* herd immunity is reached. In fact, in this simulation, total cases only overshoots *a tiny bit* above herd immunity – the UK's plan! At that point, R <1,youcanletgoofallotherinterventions,andCOVID-19stayscontained!Well,exceptforoneproblem...
That was the other finding of the March 16 Imperial College report, which convinced the UK to abandon its original plan. Any attempt at **mitigation** (reduce R, but R > 1) will fail. The only way out is **suppression** (reduce R so that R <1).
Let's see what happens if we *crush* the curve with a 5-month lockdown, reduce <iconi></icon> to nearly nothing, then finally –*finally*– return to normal life:
This is the "second wave" everyone's talking about. As soon as we remove the lockdown, we get R > 1 again. So, a single leftover <iconi></icon> (or imported <spanclass="nowrap"><iconi></icon>)</span> can cause a spike in cases that's almost as bad as if we'd done Scenario 0: Absolutely Nothing.
[^lockdown_harvard]: “Absent other interventions, a key metric for the success of social distancing is whether critical care capacities are exceeded. To avoid this, prolonged or intermittent social distancing may be necessary into 2022.” [Kissler and Tedijanto et al](https://science.sciencemag.org/content/early/2020/04/14/science.abb5793)
**Here's a simulation:** (After playing the "recorded scenario", you can try simulating your *own* lockdown schedule, by changing the sliders *while* the simulation is running! Remember you can pause & continue the sim, and change the simulation speed)
This *would* keep cases below ICU capacity! And it's *much* better than an 18-month lockdown until a vaccine is available. We just need to... shut down for a few months, open up for a few months, and repeat until a vaccine is available. (And if there's no vaccine, repeat until herd immunity is reached... in 2022.)
**Mental Health:** Loneliness is one of the biggest risk factors for depression, anxiety, and suicide. And it's as associated with an early death as smoking 15 cigarettes a day.[^loneliness]
[^loneliness]: See [Figure 6 from Holt-Lunstad & Smith 2010](https://journals.sagepub.com/doi/abs/10.1177/1745691614568352). Of course, big disclaimer that they found a *correlation*. But unless you want to try randomly assigning people to be lonely for life, observational evidence is all you're gonna get.
**Financial Health:** "What about the economy" sounds like you care more about dollars than lives, but "the economy" isn't just stocks: it's people's ability to provide food & shelter for their loved ones, to invest in their kids' futures, and enjoy arts, foods, videogames – the stuff that makes life worth living. And besides, poverty *itself* has horrible impacts on mental and physical health.
[^timeline]: **3 days on average to infectiousness:** “Assuming an incubation period distribution of mean 5.2 days from a separate study of early COVID-19 cases, we inferred that infectiousness started from 2.3 days (95% CI, 0.8–3.0 days) before symptom onset” (translation: Assuming symptoms start at 5 days, infectiousness starts 2 days before = Infectiousness starts at 3 days) [He, X., Lau, E.H.Y., Wu, P. et al.](https://www.nature.com/articles/s41591-020-0869-5)
**4 days on average to infecting someone else:** “The mean [serial] interval was 3.96 days (95% CI 3.53–4.39 days)” [Du Z, Xu X, Wu Y, Wang L, Cowling BJ, Ancel Meyers L](https://wwwnc.cdc.gov/eid/article/26/6/20-0357_article)
**5 days on average to feeling symptoms:** “The median incubation period was estimated to be 5.1 days (95% CI, 4.5 to 5.8 days)” [Lauer SA, Grantz KH, Bi Q, et al](https://annals.org/AIM/FULLARTICLE/2762808/INCUBATION-PERIOD-CORONAVIRUS-DISEASE-2019-COVID-19-FROM-PUBLICLY-REPORTED)
[^pre_symp]: “We estimated that 44% (95% confidence interval, 25–69%) of secondary cases were infected during the index cases’ presymptomatic stage” [He, X., Lau, E.H.Y., Wu, P. et al](https://www.nature.com/articles/s41591-020-0869-5)
This is called **contact tracing**. It's an old idea, was used at an unprecedented scale to contain Ebola[^ebola], and now it's core part of how Taiwan & South Korea are containing COVID-19!
[^ebola]: “Contact tracing was a critical intervention in Liberia and represented one of the largest contact tracing efforts during an epidemic in history.” [Swanson KC, Altare C, Wesseh CS, et al.](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6152989/)
(It also lets us use our limited tests more efficiently, to find pre-symptomatic <spanclass="nowrap"><iconi></icon>s</span> without needing to test almost everyone.)
Traditionally, contacts are found with in-person interviews, but those *alone* are too slow for COVID-19's ~48 hour window. That's why contact tracers need help, and be supported by –*NOT* replaced by – contact tracing apps.
(This idea didn't come from "techies": using an app to fight COVID-19 was first proposed by [a team of Oxford epidemiologists](https://science.sciencemag.org/content/early/2020/04/09/science.abb6936).)
Wait, apps that trace who you've been in contact with?... Does that mean giving up privacy, giving in to Big Brother?
Heck no! **[DP-3T](https://github.com/DP-3T/documents#decentralized-privacy-preserving-proximity-tracing)**, a team of epidemiologists & cryptographers (including one of us, Marcel Salathé) is *already* making a contact tracing app – with code available to the public – that reveals **no info about your identity, location, who your contacts are, or even *how many contacts* you've had.**
(& [here's the full comic](https://ncase.me/contact-tracing/))
Along with similar teams like TCN Protocol[^tcn] and MIT PACT[^pact], they've inspired Apple & Google to bake privacy-first contact tracing directly into Android/iOS.[^gapple] (Don't trust Google/Apple? Good! The beauty of this system is it doesn't *need* trust!) Soon, your local public health agency may ask you to download an app. If it's privacy-first with publicly-available code, please do!
[^gapple]: [Apple and Google partner on COVID-19 contact tracing technology ](https://www.apple.com/ca/newsroom/2020/04/apple-and-google-partner-on-covid-19-contact-tracing-technology/). Note they're not making the apps *themselves*, just creating the systems that will *support* those apps.
But what about folks without smartphones? Or infections through doorknobs? Or "true" asymptomatic cases? Contact tracing apps can't catch all transmissions... *and that's okay!* We don't need to catch *all* transmissions, just 60%+ to get R <1.
[^rant]: Lots of news reports – and honestly, many research papers – did not distinguish between "cases who showed no symptoms when we tested them" (pre-symptomatic) and "cases who showed no symptoms *ever*" (true asymptomatic). The only way you could tell the difference is by following up with cases later.
Which is what [this study](https://wwwnc.cdc.gov/eid/article/26/8/20-1274_article) did. (Disclaimer: "Early release articles are not considered as final versions.") In a call center in South Korea that had a COVID-19 outbreak, "only 4 (1.9%) remained asymptomatic within 14 days of quarantine, and none of their household contacts acquired secondary infections."
So that means "true asymptomatics" are rare, and catching the disease from a true asymptomatic may be even rarer!
[^oxford]: From the same Oxford study that first recommended apps to fight COVID-19: [Luca Ferretti & Chris Wymant et al](https://science.sciencemag.org/content/early/2020/04/09/science.abb6936/tab-figures-data) See Figure 2. Assuming R<sub>0</sub> = 2.0, they found that:
* Symptomatics contribute R = 0.8 (40%)
* Pre-symptomatics contribute R = 0.9 (45%)
* Asymptomatics contribute R = 0.1 (5%, though their model has uncertainty and it could be much lower)
* Environmental stuff like doorknobs contribute R = 0.2 (10%)
And add up the pre- & a-symptomatic contacts (45% + 5%) and you get 50% of R!
Thus, even without 100% contact quarantining, we can get R <1*without a lockdown!*Muchbetterforourmental&financialhealth.(Asforthecosttofolkswhohavetoself-isolate/quarantine,*governments should support them*–payforthetests,jobprotection,subsidizedpaidleave,etc.Stillwaycheaperthanintermittentlockdown.)
We then keep R <1untilwehaveavaccine,whichturnssusceptible<spanclass="nowrap"><icons></icon>s</span> into immune <spanclass="nowrap"><iconr></icon>s.</span> Herd immunity, the *right* way:
(Note: this calculator pretends the vaccines are 100% effective. Just remember that in reality, you'd have to compensate by vaccinating *more* than "herd immunity", to *actually* get herd immunity)
But what if things *still* go wrong? Things have gone horribly wrong already. That's fear, and that's good! Fear gives us energy to create *backup plans*.
Remember, even if we can't get R <1,reducingRstillreducesthe"overshoot"intotalcases,thussavinglives.Butstill,R<1istheideal,sohere'safewotherwaystoreduceR:
[^incoming]: “None of these surgical masks exhibited adequate filter performance and facial fit characteristics to be considered respiratory protection devices.” [Tara Oberg & Lisa M. Brosseau](https://www.sciencedirect.com/science/article/pii/S0196655307007742)
[^outgoing]: “The overall 3.4 fold reduction [70% reduction] in aerosol copy numbers we observed combined with a nearly complete elimination of large droplet spray demonstrated by Johnson et al. suggests that surgical masks worn by infected persons could have a clinically significant impact on transmission.” [Milton DK, Fabian MP, Cowling BJ, Grantham ML, McDevitt JJ](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3591312/)
[^homemade]: [Davies, A., Thompson, K., Giri, K., Kafatos, G., Walker, J., & Bennett, A](https://www.cambridge.org/core/journals/disaster-medicine-and-public-health-preparedness/article/testing-the-efficacy-of-homemade-masks-would-they-protect-in-an-influenza-pandemic/0921A05A69A9419C862FA2F35F819D55) See Table 1: a 100% cotton T-shirt has around 2/3 the filtration efficiency as a surgical mask, for the two bacterial aerosols they tested.
To put a number on it: surgical masks *on the sick person* reduce cold & flu viruses in aerosols by 70%.[^outgoing] Reducing transmissions by 70% would be as large an impact as a lockdown!
However, we don't know for sure the impact of masks on COVID-19 *specifically*. In science, one should only publish a finding if you're 95% sure of it. (...should.[^replication]) Masks, as of May 1st 2020, are less than "95% sure".
[^replication]: Any actual scientist who read that last sentence is probably laugh-crying right now. See: [p-hacking](https://en.wikipedia.org/wiki/Data_dredging), [the replication crisis](https://en.wikipedia.org/wiki/Replication_crisis))
However, pandemics are like poker. **Make bets only when you're 95% sure, and you'll lose everything at stake.** As a recent article on masks in the British Medical Journal notes,[^precautionary] we *have* to make cost/benefit analyses under uncertainty. Like so:
[^precautionary]: “It is time to apply the precautionary principle” [Trisha Greenhalgh et al \[PDF\]](https://www.bmj.com/content/bmj/369/bmj.m1435.full.pdf)
Cost: If homemade cloth masks (which are ~2/3 as effective as surgical masks[^homemade]), super cheap. If surgical masks, more expensive but still pretty cheap.
Benefit: Even if it's a 50–50 chance of surgical masks reducing transmission by 0% or 70%, the average "expected value" is still 35%, same as a half-lockdown! So let's guess-timate that surgical masks reduce R by up to 35%, discounted for our uncertainty. (Again, you can challenge our assumptions by turning the sliders up/down)
[^mask_args]: **"We need to save supplies for hospitals."** *Absolutely agreed.* But that's more of an argument for increasing mask production, not rationing. In the meantime, we can make cloth masks.
**"They're hard to wear correctly."** It's also hard to wash your hands according to the WHO Guidelines – seriously, "Step 3) right palm over left dorsum"?! – but we still recommend handwashing, because imperfect is still better than nothing.
**"It'll make people more reckless with handwashing & social distancing."** Sure, and safety belts make people ignore stop signs, and flossing makes people eat rocks. But seriously, we'd argue the opposite: masks are a *constant physical reminder* to be careful – and in East Asia, masks are also a symbol of solidarity!
Masks *alone* won't get R <1.Butifhandwashing&"Test,Trace,Isolate"onlygetsustoR =1.10,havingjust1/3ofpeoplewearmaskswouldtipthatovertoR<1,viruscontained!
Okay, this isn't an "intervention" we can control, but it will help! Some news outlets report that summer won't do anything to COVID-19. They're half right: summer won't get R <1,butit*will*reduceR.
For COVID-19, every extra 1° Celsius (2.2° Fahrenheit) makes R drop by 1.2%.[^heat] The summer-winter difference in New York City is 15°C (60°F), so summer will make R drop by 18%.
[^heat]: “One-degree Celsius increase in temperature [...] lower[s] R by 0.0225” and “The average R-value of these 100 cities is 1.83”. 0.0225 ÷ 1.83 = ~1.2%. [Wang, Jingyuan and Tang, Ke and Feng, Kai and Lv, Weifeng](https://papers.ssrn.com/sol3/Papers.cfm?abstract_id=3551767)
But we wouldn't have to be 2-months-closed / 1-month-open over & over! Because R is reduced, we'd only need one or two more "circuit breaker" lockdowns before a vaccine is available. (Singapore had to do this recently, "despite" having controlled COVID-19 for 4 months. That's not failure: this *is* what success takes.)
**Even under a pessimistic scenario, it *is* possible to beat COVID-19, while protecting our mental and financial health.** Use the lockdown as a "reset button", keep R <1withcaseisolation+privacy-protectingcontracttracing+at*least*clothmasksforall...andlifecangetbacktoanormal-ish!
Sure, you may have dried-out hands. But you'll get to invite a date out to a comics bookstore! You'll get to go out with friends to watch the latest Hollywood cash-grab. You'll get to people-watch at a library, taking joy in people going about the simple business of *being alive.*
[^SARS immunity]: “SARS-specific antibodies were maintained for an average of 2 years [...] Thus, SARS patients might be susceptible to reinfection ≥3 years after initial exposure.” [Wu LP, Wang NC, Chang YH, et al.](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851497/) "Sadly" we'll never know how long SARS immunity would have really lasted, since we eradicated it so quickly.
[^cold immunity]: “We found no significant difference between the probability of testing positive at least once and the probability of a recurrence for the beta-coronaviruses HKU1 and OC43 at 34 weeks after enrollment/first infection.” [Marta Galanti & Jeffrey Shaman (PDF)](http://www.columbia.edu/~jls106/galanti_shaman_ms_supp.pdf)
[^unclear]: “Once a person fights off a virus, viral particles tend to linger for some time. These cannot cause infections, but they can trigger a positive test.” [from STAT News by Andrew Joseph](https://www.statnews.com/2020/04/20/everything-we-know-about-coronavirus-immunity-and-antibodies-and-plenty-we-still-dont/)
[^monkeys]: From [Bao et al.](https://www.biorxiv.org/content/10.1101/2020.03.13.990226v1.abstract) *Disclaimer: This article is a preprint and has not been certified by peer review (yet).* Also, to emphasize: they only tested re-infection 28 days later.
**Here's a simulation starting with 100% <spanclass="nowrap"><iconr></icon>**,</span> exponentially decaying into susceptible, no-immunity <spanclass="nowrap"><icons></icon>s</span> after 1 year, on *average*, with variation:
In previous simulations, we only had *one* ICU-overwhelming spike. Now, we have several, *and*<iconi></icon> cases come to a rest *permanently at* ICU capacity. (Which, remember, we *tripled* for these simulations)
Counterintuitively, summer makes the spikes worse *and* regular! This is because summer reduces new <spanclass="nowrap"><iconi></icon>s,</span> but that in turn reduces new immune <spanclass="nowrap"><iconr></icon>s.</span> Which means immunity plummets in the summer, *creating* large regular spikes in the winter.
**To be clear: this is unlikely.** Most epidemiologists expect a vaccine in 1 to 2 years. Sure, there's never been a vaccine for any of the other coronaviruses before, but that's because SARS was eradicated quickly, and "the" common cold wasn't worth the investment.
Still, infectious disease researchers have expressed worries: What if we can't make enough?[^vax_enough] What if we rush it, and it's not safe?[^vax_safe]
[^vax_enough]: “If a coronavirus vaccine arrives, can the world make enough?” [by Roxanne Khamsi, on Nature](https://www.nature.com/articles/d41586-020-01063-8)
[^vax_safe]: “Don’t rush to deploy COVID-19 vaccines and drugs without sufficient safety guarantees” [by Shibo Jiang, on Nature](https://www.nature.com/articles/d41586-020-00751-9)
1) Do intermittent or loose R <1interventions,toreach"naturalherdimmunity".(Warning:thiswillresultinmanydeaths&damagedlungs.*And*won'tworkifimmunitydoesn'tlast.)
2) Do the R <1interventionsforever.Contacttracing&wearingmasksjustbecomesanewnorminthepost-COVID-19world,likehowSTItests&wearingcondomsbecameanewnorminthepost-HIVworld.
3) Do the R <1interventionsuntilwedeveloptreatmentsthatmakeCOVID-19way,waylesslikelytoneedcriticalcare.(Whichweshouldbedoing*anyway!*)ReducingICUuseby10xisthesameasincreasingourICUcapacityby10x:
**Here's a simulation of *no* lasting immunity, *no* vaccine, and not even any interventions – just slowly increasing capacity to survive the long-term spikes:**
Maybe you'd like to challenge our assumptions, and try different R<sub>0</sub>'s or numbers. Or try simulating your *own* combination of intervention plans!
This basic "epidemic flight simulator" has taught us so much. It's let us answer questions about the past few months, next few months, and next few years.
Teams of epidemiologists and policymakers ([left](https://www.americanprogress.org/issues/healthcare/news/2020/04/03/482613/national-state-plan-end-coronavirus-crisis/), [right](https://www.aei.org/research-products/report/national-coronavirus-response-a-road-map-to-reopening/ ), and [multi-partisan](https://ethics.harvard.edu/covid-roadmap)) have come to a consensus on how to beat COVID-19, while protecting our lives *and* liberties.
**For everyone:** Respect the lockdown so we can get out of Phase I asap. Keep washing those hands. Make your own masks. Download a *privacy-protecting* contact tracing app when those are available next month. Stay healthy, physically & mentally! And write your local policymaker to get off their butt and...
**For policymakers:** Make laws to support folks who have to self-isolate/quarantine. Hire more manual contact tracers, *supported* by privacy-protecting contact tracing apps. Direct more funds into the stuff we should be building, like...
Don't downplay fear to build up hope. Our fear should *team up* with our hope, like the inventors of airplanes & parachutes. Preparing for horrible futures is how we *create* a hopeful future.