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Pandemic strategies - comparing herd immunity and flattening the curve

Posted at 12:05 on 17 Mar 2020 by Pandora / Blake

Tags: COVID-19, health, pandemic, Patreon, politics, strategy

This post is about government and individual pandemic strategy, what I'm doing, and what I recommend you do too.

If you're in a country which is still figuring this out Iike the UK or US, I'm hoping to convince you to lay in a month or two's supplies as soon as possible, minimise social contact while doing so, and stay home for 4-8 weeks. Not everone can self-isolate, so if you can, I consider it a civic responsibility to do so.

I planned this post yesterday morning. By the time I got time to write it in the evening, the UK government released more information about the rapidly changing landscape, and my planned post is already out of date. I'm writing this as quickly as I can on my phone. It won't be the exhaustively referenced post I'd planned. 

Disclaimer: I'm not an epidemiologist or a virologist. I'm someone who can look at charts. I've looked at a lot of charts over the last two weeks. I'll link some of them in this post; if you like making data driven decisions I recommend looking at them too.

Herd immunity - the UK government's strategy

As of last night, the government are recommending drastic social isolation for high risk groups, and reduced social contact for everyone else.

  • Everyone should avoid gatherings and crowded places, such as pubs, clubs and theatres
  • Everyone should work from home if they can
  • All "unnecessary" visits to friends and relatives in care homes should cease
  • By next weekend, those with the most serious health conditions must be "largely shielded from social contact for around 12 weeks"
  • The UK is now "three weeks" behind Italy - the worst-hit country in Europe
  • If one person in any household has a persistent cough or fever, everyone living there must stay at home for 14 days
  • Those people should, if possible, avoid leaving the house "even to buy food  or essentials" - but they may leave the house "for exercise and, in that case, at a safe distance from others"
  • Schools will not be closed for the moment
  • Chief medical adviser Prof Chris Whitty said the group of people who should  take "particular care to minimise their social contact" were:
    • People over the age of 70
    • Other adults who would normally be advised to have the flu vaccine (such as those with chronic diseases)
    • Pregnant women

Mr Johnson said "drastic action" was needed as the UK approaches "the fast  growth part of the upward curve" in the number of cases.

I fear these measures are too late, and not stringent enough. 

We've had the data from Wuhan for a couple of months. We've had the data from  Italy for weeks. We've had time to build new hospitals, make new masks and ventilators, slow the infection rate by imposing these measures two  weeks ago. We didn't do that.

Instead we had an inconsistent, incoherent government response released in dribs and drabs. First they talked about letting 60% of the populace catch it to create herd immunity and reduce  the total number of infections. This was incomprehensible to me until I  read this article: Modelling Herd Immunity

It posits that "drastic" measures of total quarantine are only sustainable for three weeks. Longer than that and either people will break quarantine, or they'll become so destitute that  the poverty will have its own death toll. It predicts that letting more low risk individuals catch it before imposing social restrictions will  result in a lower total number of cases, because each person with immunity halts the spread of the virus.

That's what the government have been doing by not banning large gatherings and by not imposing all the measures they've brought in this evening two weeks ago. They've  left the schools open. Until today, housemates and family members of symptomatic individuals weren't quarantined. They've been deliberately letting people infect each other. 

Now, they've acted to slow the  infection rate. Will it work?

Flattening the curve

The virus has a 5.5 day incubation period. Of the people who caught it over the last fortnight, many are already showing symptoms.

"More than 1,500 people have tested positive for the virus in the UK - but  the actual number of cases is estimated to be between 35,000 and  50,000." (BBC)

The others are a ticking time bomb - incubating, infectious, walking around, waiting to develop symptoms.

It  takes 17.5 days for the virus to kill someone. We've had 55 reported UK deaths already. That's double what it was two days ago. This is an exponential curve. 

We're going to see the death rate continue to double, and the number of cases continue to explode.

Once a certain percentage of  the population has even infected, the country runs out of hospital beds. Seriously ill patients will need intensive care. They'll need oxygen. Some will need ventilators. 

The UK is planning to sequester beds in unused hotels, and to try to get industrial companies to help make  ventilators and other equipment. They're bringing recently retired  doctors and nurses back and retraining people in respiratory specialisms. But is this enough?

We've seen how it's gone in Wuhan and Italy. Cases flood the hospitals. There's not enough  equipment, so doctors need to make choices who lives and who dies. There are no shifts any more - medical workers work til they drop. They get exhausted. If there aren't enough masks, they get dehydrated from avoiding taking the mask off to drink, as there isn't another to replace it. Doctors and nurses get sick. They stop being able to work. Mortality spikes. People with trauma, strokes and other health problems  can't get treated. They die too. It's a runaway effect.

Most  people - 80% - will have a clinically mild illness. A bad flu. Uncomfortable, but you can weather it at home. 20% will develop pneumonia or breathing problems and need hospitalising. 3% will be seriously ill and need intensive care. 

With an overloaded health system, mortality is 4%. In countries that slowed down the spread of the disease so it never swamped their healthcare system, mortality stayed  below 1%.

This is called flattening the curve.  

A few days ago, I  shared around a post entitled Coronavirus - act today or people will die. It contains lots of charts. Its a data driven analysis of why early and radical social isolation is absolutely necessary to prevent runaway infection rates and elevated mortality.

The UK has chosen a different strategy. Our government has decided to delay intervention to allow the infection to spread. It's a risky strategy. They're gambling that when the first peak hits, they can act fast enough to slow it down so that it won't overwhelm the healthcare service. 

I think they've woefully underestimated how quickly these runaway effects can take place, and how easy they'll be to control once they've started.

In the UK, to flatten the curve we should have implemented maximum social  isolation a week ago. All non essential personnel staying at home for  two months. We should have given people a week's warning to get  supplies. Banned large gatherings two weeks ago. Imposed strict  quarantine on any households where someone had symptoms. Told high risk  individuals - those over 60, immunocompromised, with hypertension or  heart conditions - to totally self isolate.  

Most people can't  afford to stay home. So this would have needed to be funded: statutory sick pay to affected individuals on hourly pay, and subsidising  companies to provide paid leave for salaried employees.

We didn't do that. We still haven't done that. Now I fear we're facing a worst case scenario: exponential infection rates, leading to an overloaded healthcare system and a mortality rate ten times higher than if we'd acted sooner to slow the spread of infection.

The two strategies - herd immunity and flattening the curve - are diametrically opposed. With herd immunity, you want as many healthy, young people as possible to catch it as quickly as possible. It becomes brave and selfless to go to a large gathering and spread it around, to get sick early and develop immunity. With flattening the curve, you want to assume you're infectious and avoid spreading it. It becomes brave and selfless to stay home and go into voluntary self-isolation, to cancel your appointments and take the income hit. This advice is so contradictory, it's no wonder people are confused.

The UK government's strategy seems to have been to let the virus spread for 2 weeks, and now to introduce a few measures to start trying to halt it. It's totally untested, and it's the opposite of the fast-and-thorough social isolation that's been successful in countries like South Korea. The rest of the world is shaking their heads in bewilderment and sorrow at our ignorance. 

Through the last two weeks of "keep calm and carry on", the Government hasn't taken responsibility for safeguarding vulnerable populations. There was no consistent messaging that elderly people, immunocompromised people and people with hypertension, heart  conditions or diabetes etc should start self-isolating two weeks ago. Kids are going to spread infections around schools and take them home to parents who might be high risk and doing social distancing. The "herd immunity" strategy as practised seems to be totally cavalier about the death of high risk people. And I'm not at all convinced that slowing the spread of infection now they've switched strategy will be as easy as they seem to think.  

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.

- I’m an epidemiologist. When I heard about Britain’s ‘herd immunity’ coronavirus plan, I thought it was satire 

There are 65 million people in the UK. If 50 million people catch the virus, with a 1% mortality rate (that assumes we successfully slow down the rate of infection by practising radical social isolation early and consistently), 500 000 people in the UK are going to die. If we don't slow it down, and the mortality rate goes up as high as 4%, that's 2 million. There are 1.5 million lives at stake in this country.

The UK Government has drastically underestimated this virus, and overestimated our capacity to provide medical care for the spike of new cases they have knowingly caused. Their cavalier attitude over the last two weeks has been unforgivable. I'm shocked, outraged, and appalled. Beyond 1% mortality, every life lost will be on their hands.

What can you do?

Stay the fuck home. Cancel everything. Disrupt your lives to avoid losing them.   

Pull your kids out of school. Video chat your grandparents. 

Assume you have the virus, aren't symptomatic yet, and are contagious. Act accordingly.

Don’t wait to cancel until things are demonstrably really bad; this leaves available only the most socially disruptive interventions (like closing schools). Measures as extreme as closing schools tend to burden vulnerable populations the most. (E.g., because the poorest kids only eat at school). If you’re in a position to help kids in these scenarios, try to give money directly; the case for this is well established. When elementary schools close, it also makes it harder for health workers, teachers, city officials, etc. to get to work and keep things on track. Kids may have nowhere to go when parents are at work. Aggressive social distancing measures are never too late, but they are most effective at flattening the curve if undertaken before 1-2% of the population is infected [ I read this somewhere but lost the citation, please DM if you can help]. It isn’t just large events to avoid, even small meetings can have consequences.

- Flatten the Curve

Not everyone can stay home, so if you can, I consider it a civic duty to do so to reduce social congestion in your neighbourhood.

If  you didn't stock up yet, do it now. Order things online. Drive or walk to the shops, avoid public transport. Wear a mask if you have one. Medical gloves to leave the house, bin them when you get home. 

In a pandemic, you might want to minimize how much you have to go to store to buy things. Future-you might really appreciate that you did that.  Stores are filled with people who can have germs and also cough; you  might become sick and not feel up to going out to the store, and also  contagious; stores might run out of things you need either because  everyone else cleans out the inventory like before a blizzard/hurricane, or because the truck drivers are too sick to bring new inventory or the  makers of the inventory are too sick to make new inventory. Also, in the worst case scenarios, you and the store might be on opposite sides  of a quarantine perimeter.

- So Maybe We're Having a Pandemic

I propose the following personal preparation goals:

  • Against being too debilitated by sickness/exhaustion: at least two weeks easy-prep/no-prep food, and ideally one month.
  • Against being unable to source food and other domestic supplies: at least one month stored, ideally two months.
  • Against disruptions to manufacturing and supply chain: at least two  months critical medications/medical supplies, ideally six months.

-  Preparing for the Pandemic: Timeline & Food<

Disinfect your shopping. We've been using a mix of 70% rubbing alcohol with a  couple of squirts of washing up liquid, but we've got a bottle of high grade veterinary disinfectant on the way. Disinfect the surfaces of your house that people touch - doorknobs, doorframes, drawer handles, worktops. The virus can survive for days on metals and plastics.

As soon as you've got your essentials, stay home. Even if you aren't high risk. Avoid infecting anyone. If you don't have it yet, avoid any social contact that might expose you to it. 

You want to ideally not catch it until a vaccine is developed. If you do catch it, you want it to be as late as possible, once the medical processes have the benefit of experience, once there's been time to build new hospitals, make new masks and ventilators, train new doctors and nurses. 

We are not going to have the problem of not enough people catching it. The task now is to slow it down as much as possible.

Aim to stay home for 8 weeks if you can. Go for walks every day if you can to get some daylight, staying 2-3 metres away from anyone. Hang out in your garden. Do yoga. Figure out how to earn money online.

If you have kids to look after you won't get much work done. That's okay. This is about our individual and collective survival. Staying home is bad for the economy, but dying is worse. No-one's going to be able to afford to pay their rent, mortgage or utilities for a while. In France, the Government just suspended all rent and bills payments. The UK is going to have to figure this shit out. If we all just collectively stop paying en masse, it's not like they'll be able to find someone else to move in. 

What I'm doing

From yesterday onwards, I'm staying home. We're on voluntary lockdown. No-one in, no-one out. None of us have symptoms yet. I want to keep it that way, and in case we're asymptomatically infected, I want to avoid infecting anyone else.

Ten days ago I started ordering supplies for a two month quarantine. I planned for no resupply, no social contact, no leaving the house for 8  weeks. At least 2 months worth of shelf stable food for me, my partner and our kid; loo roll and cleaning supplies; cat litter and cat food; soap and laundry detergent; condoms; menstrual supplies; vitamins.

We restocked the medicine chest, including our regular prescriptions and anything we might want if were laid up sick with the flu for a week or two. We planned two weeks of easy microwave meals to freeze, so we can  eat if we get ill. We started doing the batch cooking today - later than I wanted, but the last week has been so busy.

Last week our childcare provider told us they had a cough and a fever. We asked them to stay home. My partner and I teamed the childcare for a week. We both got less done, but neither of us is sick yet.

On Thursday we went away to visit our little one's grandparents. All four of them - my  parents, F's parents, and us. By the time we left the whole of Italy was on lockdown. As we got in the car I wondered if it was a stupid thing to do, but none of us  had symptoms yet, and no-one else in the UK seemed to be aware of the urgency of the threat. This  visit, getting the two halves of the family together, had been planned for nearly a year. So we went, and spent the weekend convincing them to take the pandemic seriously, sharing our research, and persuading the older couple to start to self-isolate. By the time we left they'd cancelled their plans. My parents tried to arrange a meetup with some nearby relatives, but I asked them to postpone. I felt relieved that they were listening to me.

We came home yesterday. My partner cancelled their date yesterday evening. We're in self-isolation now. Unless we can get stuff delivered to the house - and I expect those systems will start to break down soon - we're going to make do with what we've got. We disinfected the house yesterday, and we'll be disinfecting everything that gets delivered.

I've cancelled my holiday at the end of the month, numerous visits with friends, paid shoots and sessions. Events I was looking forward to have been cancelled. I'm glad. Glad people are taking it seriously and opting out of large gatherings, before the government recommended it. This proactive social isolation is what we need.

Why am I doing this when we don't have symptoms? The biggest reason is my child. 20% of people who catch this need hospitalisation, and a lot more get a serious flu that lays them up horizontal in bed with a fever for a few days. My partner needs a hip replacement (which have all been cancelled) and has impaired mobility. Specifically, their damaged hip can't bear the weight of carrying our child. So I need to be on my feet. 

If I'm hospitalised, my partner unfortunately would need support with childcare. And if I've got it, they've probably got it. So we'd need to ask in help. We don't want to risk exposing a friend or relative. My plan is to catch it late enough that there are people in our community who have already had it, who can come over and help out without putting themselves at risk.

I've made contingency childcare plans with a friend who's done babysitting before, who has agreed to take the munchkin if the worst happens. I've bought a big tub of formula in case I can't breastfeed. If we don't need it, I'll donate it to a food bank once this has all blown over.

This week I'm going to be writing a will. It's a sombre time. But making arrangements is only practical. I recommend you do the same.

Work and money

I'm lucky that I already work from home. I'm unlucky that I'm self-employed and don't have paid sick leave. I'm lucky that I have a bit saved. I'm unlucky that some of my savings is in bitcoin, which has crashed along with the rest of the stock market as everyone tries to liquidate their assets at once. There are other freelancers who help me put my content together who depend on me for paying work. I want to be able to keep taking advantage of their help, and keep paying them as long as possible.

I've already lost several days of paid work through cancellations. I'm making plans to shift more of my offerings online. 

In the realm of sex work, I'm editing new content on Dreams of Spanking. I'm offering custom kinky audio recordings and solo videos. I'm going to mail all my clients and offer phone and webcam sessions. I'm also thinking of offering kink and relationships coaching.

As for the rest of my work: I'll post new writing here every week or more. I'm thinking of creating digital PDF downloads and producing new webinars. I don't know how many people are going to be able to afford to pay for things online, but with everyone stuck at home, I'm hoping that there'll still be a market for virtual education and entertainment.

Are you also thinking of developing new online offerings? Let's chat. I'm open to collaborations. We're stronger together.

Thank you for your support, which means I'm in a much better position to weather this storm than if I didn't have this Patreon. If you get into dire financial straits and need to cancel it, I'll understand. Feel free to continue to follow - most of my writing is going to be public from now on. 

Leave a comment and tell me: how are you feeling? What are your thoughts and fears about this crisis? What's your plan, and what obstacles are blocking it?  Is there anything more I can do to brighten the weeks ahead? 

Let's keep each other company,  keep talking, and keep connected.

I'm able to write posts like this one thanks to my 91 Patreon sponsors - thank you all so much! If you found this post useful and would like me to write more, click here to become a Patron.


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