Corona virus poses such a massive threat that, besides virologists and politicians, medical laymen too should be allowed to express their opinion. Scientific statements concerning Covid-19 are now so well documented that, in addition to the two known courses of this epidemic, a third alternative may be envisaged – at least theoretically. The two known ones are first, the “Natural Outburst”, and second, “Imposed Quarantine”, as now practiced almost worldwide. The third alternative was originally envisaged in England; we could describe it as “Accelerated Immunization”.
First Alternative: the “Natural Outburst”
The plague described by Giovanni Boccaccio around the middle of the fourteenth century, killed between a third and a half of the population throughout Europe. In view of the medical knowledge available at that time, it was impossible to contain the epidemic. This was also true of the so-called Spanish flu, which killed more people than the First World War immediately preceding it. In the Middle Ages, as at the beginning of the 20th century, no government was able to prevent or even contain the spread of epidemics. The disease simply continued to rage until it had wiped out all people without sufficient immune resistance. But in Venice, when the plague broke out beyond the city, a forty-day (quaranta) isolation of all visitors was prescribed by law. Hence the name quarantine.
As long as there is no vaccine
and its development will most probably take at least a whole year, social intercourse should be restricted as much as possible to prevent the virus from being transmitted from person to person. As according to Chinese statistics the mortality rate due to Covid-19 amounts to about two percent, this means that without such imposed quarantine a population of eighty million (like Germany) would suffer the loss of 1.6 million people if the virus were allowed to spread like wildfire within the short span of one or two months. Death would hit people in their homes and on the streets, as intensive care units can only offer a fraction of the number of beds required, namely only about 28,000 in all of Germany, of which in normal times about 70% are occupied by other cases of illness anyway, (see https://www.faz.net/aktuell/wirtschaft/corona-in-deutschland-bis-wann-reichen-die-krankenhaus-betten-16676537.html), so that actually there are only about 8 400 beds available.
Let us now assume that the Chinese statisticians have been wrong by a factor of one hundred, because not all infections have been tested. In this case, only 0.02% of life-threatening cases would besiege German hospitals, but these would still represent 16,600 fatally ill people, i.e. still double what the German health system could cope with.
Second Alternative: “Imposed Quarantine”
The purpose of this alternative consists in slowing down the spread of the virus so that the number of seriously ill patients will – hopefully! – not exceed the number of beds available in existing intensive care units. This goal seems to have been successfully achieved in China (where additional hospitals were raised so to speak overnight), but not in Italy.
Important to note in this context is an insight that applies not only to Italy but to China as well. Even if it is possible to keep transmission in check by means of strict quarantine, susceptibility to the virus will continue to exist until at least 60% of the population have acquired immunity, i.e. until they develop the appropriate antibodies as a result of natural infection or artificially through vaccination. For this reason, China is now sealing its borders against the influx of foreign visitors, even after having reduced new cases at home near to zero, because ninety-nine percent of its population are still not immune at all (strict quarantine only protected them against infection). In other words, the danger of new outbreaks of Covid-19 is by not averted in the Far East either.
Nevertheless, the policy of imposed quarantine can be successful in the end if it succeeds in curbing the infection up to the point where a vaccine is available and the immunization of at least sixty percent of the population then succeeds by means of artificial but harmless infection (i.e. through vaccination). Since this can take up to a year or even more, alternative 2 implies that all social and economic life together with cross-border traffic remains exposed to almost complete paralysis during this period – with unforeseeable consequences.
Alternative three: “Accelerated immunization”
There is a third alternative that would avoid such paralysis. From the data available in China, we know that Covid-19 is particularly dangerous for people over 60 years of age. About a quarter of all people over eighty fall victim to the virus, between 60 and 80 this applies to only six percent, and below sixty the percentage is quite low. In general, there is a 27.4% probability of dying from Corvid-19 for people over 60 years of age, compared to only one tenth, namely 2.3%, for those under 60 (https://ourworldindata.org/coronavirus).
If these figures are correct, we must ask ourselves whether it would not make sense to limit strict quarantine to those over sixty, rather than extending it to the entire population. In the case of Germany, alternative 3 would mean that instead of 83 million people being kept in isolation with borders closed, this would only apply to about 24 million, i.e. less than a third without any restriction to normal traffic. These especially vulnerable 24 million are either already in retirement or in old people’s homes, where strict quarantine causes the fewest problems.
In contrast, two thirds of the population (in Germany about 58 million) will not be quarantined. Even in this case, mortality would, however, still reach the astronomical value of (59*2.3/100=) 1.36 million. A too rapid spread of the virus could be prevented by ensuring that all the work that can be done at home is actually done there until day x, but this would still overburden hospitals as day x will only be reached when immunity is achieved for 60% of the population, i.e. for all people up to the age of sixty over whom no quarantine has been imposed.
Without appropriate countermeasures highly contagious Covid-19 would spread within weeks over the unprotected two thirds of the population, so that a 60% immunization can probably be expected within three to four months – but somewhat longer if a larger number of employees are required to work in-house. After this time, the nightmare would be over once and for all, but at the cost of more than a million deaths in Germany. And for these people, who normally end up in hospitals before, only about 8400 intensive care beds would be available (30% of 28,000, see above) even in a country as medically well-equipped as Germany. In other words, the demand for beds would exceed the supply by more than a hundred times.*1* Strangely enough, renowned Austrian journalist Michael Lingens advocates this alternative for his country (https://www.lingens.online/2020/03/16/was-spricht-fuers-radikale-britische-modell/).
High-ranking experts such as William Hanage,
professor of Epidemiology at Harvard University, consider the “British model” a bad joke. He discusses it in the form first proposed in England, namely as “herd immunization” with little difference to alternative 1 or the “Natural Outburst”, where things are simply left to themselves. Prof. Hanage argues: “We talk about vaccines generating herd immunity, so why is this different? Because this is not a vaccine. This is an actual pandemic that will make a very large number of people sick, and some of them will die. Even though the mortality rate is likely quite low, a small fraction of a very large number is still a large number” (though much less so in the case of people over sixty staying in quarantine, which he did not consider. But even in this case the system would collapse, according to Prof. Hanage). “This would be expected to happen, even if we make the generous assumption that the government were entirely successful in restricting the virus to the low-risk population. At the peak of the outbreak the numbers requiring critical care would be greater than the number of beds available. This is made worse by the fact that people who are badly ill tend to remain so for a long time, which increases the burden.” (https://www.theguardian.com/commentisfree/2020/mar/15/epidemiologist-britain-herd-immunity-coronavirus-covid-19).
Seen in this light, only alternative two seems to be admissible. However, since we know that at least sixty percent of the population must be immunized in a natural or artificial way (that is by vaccination), everything depends on whether the vaccine is available in time. If it is not, the losses in the second alternative may be even greater than in the third, because social and economic life and all cross-border trade would be paralyzed indefinitely. The fact that China has hardly any new cases and that South Korea is also seeing a drop in their number is no proof to the contrary, because, as mentioned above, the population is almost as immune to Covid-19 today as it was at the beginning of the epidemic. If the vaccine production is too much delayed, it might even be necessary at some point to switch from alternative two to three.
1. The enormous discrepancy between supply and demand for intensive care beds also puts the accusations against neo-liberal austerity measures into perspective (as justified as they are in other respects). No state can prepare for such a crisis in normal times.
I am indebted to criticism by my son Igmar Jenner and by Prof. William E. Rees for having decisively rejected the third alternative, which I had assessed more positively in a first draft. Here is my letter in response to the corresponding objection by Mr. Rees:
I forgot to respond to your objection:
“As for your ‘alternative 3’, it is actually quite brilliant in practical if not entirely in political terms. You acknowledge yourself that there would inevitably be some deaths among the younger set, deaths that might otherwise be prevented. Would it not be rather difficult for any politician to propose something that s/he knows will result in some extra mortality even if the long-term benefit/cost ratio greatly exceeds one? (There are plenty of other circumstances in which we make this kind of decision — such as setting speed limits — but most are less sensitive and put much of the potential for negative consequences on the affected citizens. However, if you as my leader choose not to isolate me and I die, that’s your fault!) It would be particularly difficult to appease relatives of these ‘sacrifices’ for the greater economic good.”
I agree with you that no politician could justify himself to the population if he did not do everything in the first days and weeks of the crisis to prevent avoidable deaths. I am, however, afraid that he rather fears the desastrous impression produced by masses of dying people in and in front of crowded hospitals. Normal dying, not seen on television screens hardly touches anybody. We know that tens of thousands of deaths due to car crashes occur every year in all major industrialized countries. Everyone knows the fact without apparently feeling really bothered because this is part of “normality” and is happening quietly. Hospitals and undertakers have long since adjusted for it and, cynically, even GDP is benefiting from it.
Hence my objection to the word “indefinitely” in the British Corona Virus Report (concerning the duration of alternative 2). I am afraid that we will hardly be able to live in quarantine for more than two months at most, after which rules will be gradually relaxed as soon as hospitals can cope with the number of deaths. After all, people don’t bear to lead the life of prisoners and they want to work and to live. I am sure that after a relatively short period of time, they will adapt to Corona in the same way as they did and do to car accidents.
I am not saying this out of cynicism or because I believe that the economy should be more important than life – my own life or that of others -, but because, as biological beings, we are constantly living with risk and often with victims. We only forgot about this basic fact because we have become so rich during the last century. Just think that in the poorest parts of Japan, sons used to carry their old mothers and fathers to mountains to die there when food was no longer sufficient for them and their children. If we were to avoid all risk on principle, we would not be allowed to board any airplane, we would not be allowed to let our children out of sight for a moment while playing, etc.
But, to be sure, I completely agree with you that at the present moment nothing else should apply as alternative 2, but it will not surprise me if the world soon stops doing so and gradually changes to alternative 3.