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Coronavirus: The Hammer and the Dance

What the Next 18 Months Can Look Like, if Leaders Buy Us Time

Tomas Pueyo
Mar 19 · 29 min read
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  1. Coronavirus: Learning How to Dance: How the best countries are fighting the epidemic
  2. Coronavirus: The Basic Dance Steps Everybody Can Follow

  1. What options do we have?
  2. What’s the one thing that matters now: Time
  3. What does a good coronavirus strategy look like?
  4. How should we think about the economic and social impacts?

1. What’s the situation?

Last week, I showed this curve:

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  • An additional 16 countries have more cases today than Hubei when it went under lockdown: Japan, Malaysia, Canada, Portugal, Australia, Czechia, Brazil and Qatar have more than Hubei but below 1,000 cases. Switzerland, Sweden, Norway, Austria, Belgium, Netherlands and Denmark all have above 1,000 cases.

2. What Are Our Options?

Since the article last week, the conversation has changed and many countries have taken measures. Here are some of the most illustrative examples:

Measures in Spain and France

In one extreme, we have Spain and France. This is the timeline of measures for Spain:

  • Specific ban on taking kids out for a walk or seeing friends or family (except to take care of people who need help, but with hygiene and physical distance measures)
  • All bars and restaurants closed. Only take-home acceptable.
  • All entertainment closed: sports, movies, museums, municipal celebrations…
  • Weddings can’t have guests. Funerals can’t have more than a handful of people.
  • Mass transit remains open

Measures in the US and UK

The US and UK, like countries such as Switzerland, have dragged their feet in implementing measures. Here’s the timeline for the US:

  • Friday: National Emergency declared. No social distancing measures
  • Monday: the government urges the public to avoid restaurants or bars and attend events with more than 10 people. No social distancing measure is actually enforceable. It’s just a suggestion.

Option 1: Do Nothing

Before we do that, let’s see what doing nothing would entail for a country like the US:

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This fantastic epidemic calculator can help you understand what will happen under different scenarios. I’ve pasted below the graph the key factors that determine the behavior of the virus. Note that infected, in pink, peak in the tens of millions at a certain date. Most variables have been kept from the default. The only material changes are R from 2.2 to 2.4 (corresponds better to currently available information. See at the bottom of the epidemic calculator), fatality rate (4% due to healthcare system collapse. See details below or in the previous article), length of hospital stay (down from 20 to 10 days) and hospitalization rate (down from 20% to 14% based on severe and critical cases. Note the WHO calls out a 20% rate) based on our most recently available gathering of research. Note that these numbers don’t change results much. The only change that matters is the fatality rate.

How Should We Think about the Fatality Rate?

This is the same graph as before, but now looking at hospitalized people instead of infected and dead:

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If 5% of your cases require intensive care and you can’t provide it, most of those people die. As simple as that.

Additionally, recent data suggests that US cases are more severe than in China.

Collateral Damage

These numbers only show people dying from coronavirus. But what happens if all your healthcare system is collapsed by coronavirus patients? Others also die from other ailments.

What happens if you have a heart attack but the ambulance takes 50 minutes to come instead of 8 (too many coronavirus cases) and once you arrive, there’s no ICU and no doctor available? You die.

There are 4 million admissions to the ICU in the US every year, and 500k (~13%) of them die. Without ICU beds, that share would likely go much closer to 80%. Even if only 50% died, in a year-long epidemic you go from 500k deaths a year to 2M, so you’re adding 1.5M deaths, just with collateral damage.

If the coronavirus is left to spread, the US healthcare system will collapse, and the deaths will be in the millions, maybe more than 10 million.

The same thinking is true for most countries. The number of ICU beds and ventilators and healthcare workers are usually similar to the US or lower in most countries. Unbridled coronavirus means healthcare system collapse, and that means mass death.

Unbridled coronavirus means healthcare systems collapse, and that means mass death.

By now, I hope it’s pretty clear we should act. The two options that we have are mitigation and suppression. Both of them propose to “flatten the curve”, but they go about it very differently.

Option 2: Mitigation Strategy

Mitigation goes like this: “It’s impossible to prevent the coronavirus now, so let’s just have it run its course, while trying to reduce the peak of infections. Let’s just flatten the curve a little bit to make it more manageable for the healthcare system.

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Herd Immunity and Virus Mutation

The idea is that all the people who are infected and then recover are now immune to the virus. This is at the core of this strategy: “Look, I know it’s going to be hard for some time, but once we’re done and a few million people die, the rest of us will be immune to it, so this virus will stop spreading and we’ll say goodbye to the coronavirus. Better do it at once and be done with it, because our alternative is to do social distancing for up to a year and risk having this peak happen later anyways.

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The best way for this virus to mutate is to have millions of opportunities to do so, which is exactly what a mitigation strategy would provide.

So if neither doing nothing nor mitigation will work, what’s the alternative? It’s called suppression.

Option 3: Suppression Strategy

The Mitigation Strategy doesn’t try to contain the epidemic, just flatten the curve a bit. Meanwhile, the Suppression Strategy tries to apply heavy measures to quickly get the epidemic under control. Specifically:

  • Then, release the measures, so that people can gradually get back their freedoms and something approaching normal social and economic life can resume.
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All the model parameters are the same, except that there is an intervention around now to reduce the transmission rate to R=0.62, and because the healthcare system isn’t collapsed, the fatality rate goes down to 0.6%. I defined “around now” as having ~32,000 cases when implementing the measures (3x the official number as of today, 3/19). Note that this is not too sensitive to the R chosen. An R of 0.98 for example shows 15,000 deaths. Five times more than with an R of 0.62, but still tens of thousands of deaths and not millions. It’s also not too sensitive to the fatality rate: if it’s 0.7% instead of 0.6%, the death toll goes from 15,000 to 17,000. It’s the combination of a higher R, a higher fatality rate, and a delay in taking measures that explodes the number of fatalities. That’s why we need to take measures to reduce R today. For clarification, the famous R0 is R at the beginning (R at time 0). It’s the transmission rate when nobody is immune yet and there are no measures against it taken. R is the overall transmission rate.

Under a suppression strategy, after the first wave is done, the death toll is in the thousands, and not in the millions.

Why? Because not only do we cut the exponential growth of cases, we also cut the fatality rate since the healthcare system is not completely overwhelmed. Here, I used a fatality rate of 0.9%, around what we’re seeing in South Korea today, which has been most effective at following Suppression Strategy.

  1. A months-long lockdown would destroy the economy.
  2. It wouldn’t even solve the problem, because we would be just postponing the epidemic: later on, once we release the social distancing measures, people will still get infected in the millions and die.
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3. The Value of Time

In our previous post, we explained the value of time in saving lives. Every day, every hour we waited to take measures, this exponential threat continued spreading. We saw how a single day could reduce the total cases by 40% and the death toll by even more.

What if you were about to face your worst enemy, of which you knew very little, and you had two options: Either you run towards it, or you escape to buy yourself a bit of time to prepare. Which one would you choose?

This is what we need to do today. The world has awakened. Every single day we delay the coronavirus, we can get better prepared. The next sections detail what that time would buy us:

Lower the Number of Cases

With effective suppression, the number of true cases would plummet overnight, as we saw in Hubei last week.

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Source: Tomas Pueyo analysis over chart and data from the Journal of the American Medical Association
  • Immediate relief for the healthcare system and the humans who run it
  • Reduction in fatality rate
  • Reduction in collateral damage
  • Ability for infected, isolated and quarantined healthcare workers to get better and back to work. In Italy, healthcare workers represent 8% of all contagions.

Understand the True Problem: Testing and Tracing

Right now, the UK and the US have no idea about their true cases. We don’t know how many there are. We just know the official number is not right, and the true one is in the tens of thousands of cases. This has happened because we’re not testing, and we’re not tracing.

  • With a few more weeks, we could get our testing situation in order, and start testing everybody. With that information, we would finally know the true extent of the problem, where we need to be more aggressive, and what communities are safe to be released from a lockdown.
  • New testing methods could speed up testing and drive costs down substantially.
  • We could also set up a tracing operation like the ones they have in China or other East Asia countries, where they can identify all the people that every sick person met, and can put them in quarantine. This would give us a ton of intelligence to release later on our social distancing measures: if we know where the virus is, we can target these places only. This is not rocket science: it’s the basics of how East Asia Countries have been able to control this outbreak without the kind of draconian social distancing that is increasingly essential in other countries.

Build Up Capacity

The US (and presumably the UK) are about to go to war without armor.

  • We can quickly build up our production of masks, PPEs, ventilators, ECMOs, and any other critical device to reduce fatality rate.

Lower Public Contagiousness

The public is scared. The coronavirus is new. There’s so much we don’t know how to do yet! People haven’t learned to stop hand-shaking. They still hug. They don’t open doors with their elbow. They don’t wash their hands after touching a door knob. They don’t disinfect tables before sitting.

Understand the Virus

We know very very little about the virus. But every week, hundreds of new papers are coming.

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Find Treatments

Not only that, but what if we found a treatment in the next few weeks? Any day we buy gets us closer to that. Right now, there are already several candidates, such as Favipiravir, Chloroquine, or Chloroquine combined with Azithromycin. What if it turned out that in two months we discovered a treatment for the coronavirus? How stupid would we look if we already had millions of deaths following a mitigation strategy?

Understand the Cost-Benefits

All of the factors above can help us save millions of lives. That should be enough. Unfortunately, politicians can’t only think about the lives of the infected. They must think about all the population, and heavy social distancing measures have an impact on others.

4. The Hammer and the Dance

Now we know that the Mitigation Strategy is probably a terrible choice, and that the Suppression Strategy has a massive short-term advantage.

  • How expensive will it be?
  • Will there be a second peak as big as if we didn’t do anything?

The Hammer

First, you act quickly and aggressively. For all the reasons we mentioned above, given the value of time, we want to quench this thing as soon as possible.

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The Dance

If you hammer the coronavirus, within a few weeks you’ve controlled it and you’re in much better shape to address it. Now comes the longer-term effort to keep this virus contained until there’s a vaccine.

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The Dance in Successful Countries

How come South Korea, Singapore, Taiwan and Japan have had cases for a long time, in the case of South Korea thousands of them, and yet they’re not locked down home?

The Dance of R

I call the months-long period between the Hammer and a vaccine or effective treatment the Dance because it won’t be a period during which measures are always the same harsh ones. Some regions will see outbreaks again, others won’t for long periods of time. Depending on how cases evolve, we will need to tighten up social distancing measures or we will be able to release them. That is the dance of R: a dance of measures between getting our lives back on track and spreading the disease, one of economy vs. healthcare.

  • If people are trained to identify their symptoms earlier, they reduce the number of days in blue, and hence their overall contagiousness
  • If people are isolated as soon as they have symptoms, the contagions from the orange phase disappear.
  • If people are educated about personal distance, mask-wearing, washing hands or disinfecting spaces, they spread less virus throughout the entire period.

The ROI of Social Distancing

If with all these measures we’re still way above R=1, we need to reduce the average number of people that each person meets.

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  • Get a sense of the benefit of applying them: the reduction in R
  • Get a sense of their cost: the economic, social, and ethical cost.
  • Stack-rank the initiatives based on their cost-benefit
  • Pick the ones that give the biggest R reduction up till 1, for the lowest cost.
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This is for illustrative purposes only. All data is made up. However, as far as we were able to tell, this data doesn’t exist today. It needs to. For example, the list from the CDC is a great start, but it misses things like education measures, triggers, quantifications of costs and benefits, measure details, economic / social countermeasures…

Conclusion: Buy Us Time

The coronavirus is still spreading nearly everywhere. 152 countries have cases. We are against the clock. But we don’t need to be: there’s a clear way we can be thinking about this.

Share the Word

Unfortunately, millions of lives are still at stake. Share this article—or any similar one—if you think it can change people’s opinion. Leaders need to understand this to avert a catastrophe. The moment to act is now.


Thanks to Tito Hubert, Genevieve Gee, Pierre Djian, Jorge Peñalva, and Matt Bell

Tomas Pueyo

Written by

2 MSc in Engineering. Stanford MBA. Ex-Consultant. Creator of applications with >20M users. Currently leading a billion-dollar business @ Course Hero

Tomas Pueyo

Written by

2 MSc in Engineering. Stanford MBA. Ex-Consultant. Creator of applications with >20M users. Currently leading a billion-dollar business @ Course Hero

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