COVID-19: what is the endgame?

It is not my intent to be needlessly alarmist, but far too many lives are at stake for us to avoid thinking this thing through.

Right now, we are all busy reacting to this “black swan” event called the COVID-19 pandemic, what with country after country shutting down, locking down, introducing social distancing and the like, all in a bid to slow the spread of the virus. Even as all of this unfolds around us and is accompanied by the concomitant yet spectacular economic crash, I am sure some of us are wondering – where and when does this all end? What’s the endgame here, and especially so for the emerging world (Indian sub-continent, ASEAN, LATAM and Africa) where over 4 billion people or 57% of humanity resides.

Here are a few thoughts on where we are currently headed and what we can (still) do.

1.      It is not “just another flu”: action is needed

There is still a lingering view that we are over-reacting to what is just another flu virus, and I want to nip that view in the bud here. COVID-19 is at least twice as infectious as the seasonal flu (which in itself is quite infectious) and has a mortality rate between 10-20 times that of the seasonal flu. Left unchecked, it could kill tens of millions of people globally! So the “do nothing” approach will extract a very heavy cost in human life.

2.      Containment as a strategy has failed

Despite tremendous efforts including some very draconian measures by China, the virus has escalated to pandemic level, and since no country can mount a stronger containment effort than authoritarian China, it stands to reason that the virus will inevitably spread and run its course through the human population world-wide.

3.      “Flattening the curve” will not work for emerging markets

If containment won’t work anyway, why are countries in Europe and North America going into lock down mode? They are attempting to “flatten the curve”, i.e. slow down the spread of the virus so that the number of cases needing hospitalization does not exceed their hospital system capacity, as well illustrated in the chart above.

The trouble for emerging countries is that their hospital system capacity is so low that they will not be able to flatten the curve enough to bring the number of cases in line with it. This means there will be millions of sick people who will fail to get adequate medical care, resulting in a higher fatality rate. To illustrate, the US has about 3 hospital beds per 1000 people, so if they can keep the serious cases (which is about 5% of all cases) to below 0.3% of the total population, they will just about manage. India, which has 7 beds for every 10,000 people, will need to keep serious cases below 0.07% to achieve the same result, which is next to impossible.

4.      Lock-downs will not work for emerging markets and they cannot scale up healthcare in time either (by conventional means)

Yes, emerging markets could lock down their populations to make the spread of the virus really, really slow, but this would mean they would need to bring their economies to a standstill for not just 1-2 months, but for 1-2 years. That would destroy their fragile economies and end up causing even more damage than the virus itself. The other option could be to very aggressively scale up the healthcare infrastructure while slowing down the virus in parallel, but given limited budgets and large populations, this is unlikely to be feasible and/or sufficient.

   5.      In the worst case, emerging countries could see 25-40 million deaths by the end of 2021

Given all of the above, one has to assume that the virus will spread to cover about 60% of the population over a period of about two years and kill a large number of people. A big saving grace here is that emerging country populations are young, and COVID-19 disproportionately affects older people. For instance, 68% of Indonesia’s population is under 50, and the fatality rate in that age group is 0.1-0.4%, based on available estimates. However, this rate may end up being higher in these countries due to inadequate healthcare, as noted above. In the worst case, we could see 25-40 million fatalities in these countries, a shocking number compared to the current toll of about 11,000 globally. Of course, as the bulk of these cases won’t be reported, the “official figures” from these countries will not be as high and won’t tell the real story.

6.      Beyond 2021, “herd immunity” will make the virus endemic

What happens beyond the 2021 time-frame? Experts are suggesting that when a sufficiently large proportion (~60%) of the population has already been infected, “herd immunity” kicks in and the number of new cases plateaus off. In that scenario, this virus will become endemic, i.e. it will still be there, but will cause a stable and manage-able number of cases each year as many other pathogens do today.  

7.      What countries are doing (and can still do) to save lives

The current response of most emerging countries leaves cause for serious concern. There is far too little testing being done, causing potentially thousands of cases to go undetected, which could multiply within weeks and accelerate the spread of the virus. Indonesia, Africa, India and others are all ill-prepared for those many cases and their healthcare systems will be overwhelmed within a couple of months at this rate.  Mexico has taken a very casual approach as well, which is rather alarming considering their weak healthcare system. These countries need to do things rapidly, and differently from the developed world, in order to keep the loss of life to a minimum. And they need to do so without completely crippling their economies.

What should they do differently? Some ideas below, many of which are quite the opposite of what countries are currently doing:

a.      Be transparent and educate

Instead of being in denial or in reactive mode, pro-actively share information to build trust, replacing rumor with fact and panic with a cautious confidence. Educating vulnerable groups helps reduce transmission. Using mobile apps and social media for this purpose can be highly effective. Some governments, e.g. Singapore, have used WhatsApp very effectively to disseminate information instantly and directly to people.

 b.     Keep the economy going (smartly)

Prolonged lock-downs will slow down economies more than the virus and cannot be sustained – it is best to keep the economic engines running, keep people busy and employed and generate funds to invest in innovative solutions. Instead of shutting down the whole economy to slow the virus, use technology to take a more targeted approach.

c.      Take a targeted approach to testing and isolation

A targeted and hi-tech approach is more feasible and efficient for these large and populous countries, as large area shut downs will not work. Focus all testing and isolation efforts on more vulnerable individuals and use digital technology for tracing, tracking and isolation surveillance. Some countries have started tracing apps using Bluetooth/NFC to identify when people are close to someone tagged infected or at risk, so that others can be alert. Others have provided quarantined people with wrist bands which can track their location. Telecom companies and credit card companies can share information about people’s movements in a targeted way (same tech that is used to track fugitives) so that quarantine breakers can be caught and strong action taken. Image recognition and AI can similarly be used for geo-tagging and contact tracing when needed (China has shown the way here).

Similar innovation is needed in testing. Emerging nations are great at low-cost innovation – what can be done to produce billions of test kits at a low cost? What can be done to make testing more effective? Are there enzyme or gene-level markers that can use saliva to test more easily and faster? Are low-cost, rapid self-testing/home-testing kits possible as a first cut? I’m not an expert here, but I am sure there is a lot of innovation to be unlocked here, to take away testing cost/time as a barrier.

d.     Take unorthodox approaches to scaling up healthcare

Hospitals cannot be built fast enough, but hotels are lying un-utilized. Can their rooms be re-purposed? Can we train at scale pharmacists, students and even well-educated common people to increase nursing care?  Can we build cheaper ventilators (a key piece of equipment needed for lung care) and other necessary equipment to support sick people even at home? Can we build these equipment for home use by family under online video supervision and/or IoT-based sensor tracking?

e.     Pour money into developing treatment and vaccines

Emerging world talent is no less than the best of the world. The best use of money at this time is to unleash the collective innovation and research capability of our people to develop treatment options and vaccines. If successful, these would save millions of lives.

f.       Keep spirits high and collaborate

Replace the gloom-and-doom news cycle with action-oriented updates. Engage the population to make them part of the solution and not just passive victims. Instead of closing down collaboration, increase communications across countries and collaborate to pool resources, be those in medicine, research or care services. Why are we being hobbled by national borders which the virus doesn’t respect? We would be better off thinking of ourselves as one large nation battling a common enemy, rather than as competing and mutually adversarial nations.

While the next couple of years will be tough regardless of what we do, we can still save millions of lives in emerging nations by taking some of the actions above and other good ideas, unconventional and counter-intuitive as some of them may seem at first glance.