Let’s Do This One Thing to Combat Covid-19, Globally

A detailed picture of how it spreads will help all nations

This paper recommends a full-population testing regime in a relatively large ‘small’ country, such as New Zealand — for better health and economic outcomes in that country, and to deliver the world’s first detailed transmission map of the SARS-Cov-2 virus, benefiting all countries.

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The pandemic sweeping the globe today threatens a repeat of 1918, when entire armies returned home — including ANZAC troops — some infected with a new deadly form of influenza.

Issuing demobilization orders without first treating the disease, military leaders addressed the immediate needs of war-weary soldiers, less cognizant of the future. Like leaders a few months ago seeking, apparently, to favor economies, seemingly unthinking of the social and economic consequences.

Notwithstanding such decisions, however, there may now be a brief window of opportunity to create the most intimately detailed picture of Covid-19, and to present it as a neighbourly gift to the world — benefiting the citizens and businesses of all nations.

The immediate future looks grim, but the pandemic has at least one silver lining. Scaled-up, a new-found sense of shared humanity offers hope.

Neighbors helping neighbors

Millions of people seem to have forgotten what they thought divided them. Irrespective political, religious, and personal beliefs, the internet and news bulletins show countless selfless acts of kindness, empathy, and gratitude. People around the world are joining together (virtually, and more than six feet apart) to help their neighbors, support medical staff, and bring goodwill and humor to complete strangers.

Private sector firms and public agencies have also joined a collaborative movement in common cause.

Companies and politicians unite and collaborate

Companies and prominent citizens have joined forces with hospitals and local and regional agencies to supply medical expertise and supplies, wherever needed. Manufacturing plants are being re-tooled to make ventilators. Complex devices and technology that usually take months or years to develop, in secrecy, are now crowdsourced in days.

The US Department of Justice even waived legal concerns about anti-competitive behavior, allowing medical supply companies to work together: expediting the manufacture, sourcing, and distribution of coronavirus medication and personal-protective equipment.

Despite bitter and polarizing divisiveness continuing amongst some politicians and media commentators, lawmakers in many countries are working together, or at least not opposing necessary action to combat a shared danger. Increasingly, local and state politicians across the political divide are proactively sharing ideas and resources.

Countries helping countries

Countries flew medical staff and supplies to other nations. Officials everywhere pore over the actions of their overseas peers, learning lessons about successful strategies to combat Covid-19. Academics around the world put aside other research to work together, in a completely new scale of global collaboration. Researchers proactively share new findings, openly and urgently, distilling knowledge from data in weeks rather than years.

In a rare speech from the throne, Queen Elizabeth II offered a rallying message for the UK, the Commonwealth of Nations, and the world:

While we have faced challenges before, this one is different.

This time we join with all nations across the globe in a common endeavour, using the great advances of science and our instinctive compassion to heal. We will succeed — and that success will belong to every one of us.

We should take comfort that while we may have more still to endure, better days will return: we will be with our friends again; we will be with our families again; we will meet again.

This article explains how a few countries may have a unique opportunity to improve outcomes for their own citizens, and every other nation.

Next level neighborliness

Leaders of many large nations are focused on stemming a tide of death washing over their lands. Some face the terrifying horror of the exponential curve. When they get on top of it, as they will, a few smaller countries could, potentially, deliver the first detailed topographic map of the virus’ transmission mechanisms. Knowing precisely how the virus gets around would help all nations stop it in its tracks, enabling the relative calm of a vigilant ‘new normal’ until a vaccine becomes available.

The missing lesson from Singapore

Singapore, Taiwan, South Korea, and Viet Nam are regarded exemplars in containing Covid-19, generally avoiding the pain of massive loss of life and ‘last resort’ of massive, debilitating lockdowns to stop the disease’s spread. It is too early to tell for sure. (Sweden adopted a more relaxed approach, without full lockdowns, and Singapore experienced a spike in cases from overseas travelers, requiring a partial shutdown), but in some countries businesses and schools mostly remain open as citizens continue with their lives, vigilantly, until (hopefully) a vaccine is produced.

With early illustrative insights available, this article draws from Singapore. It does not suggest that Singapore is ‘the’ exemplar. Rather, ‘an’ exemplar at the early stage. Future analyses may find equally instructive or more valuable lessons from South Korea, Taiwan, Viet Nam, Germany, and elsewhere.

Singapore offers many lessons that scores of countries use in their own response to the pandemic. But, focusing on Singapore’s actions to contain the virus arguably misses why they achieved better results (or at least initially — until leaders apparently stumbled, when citizens returned from overseas with the virus, unscreened).

A world-leading crisis management firm, Levick, encapsulated the ethos likely behind Singapore’s initial response in the headline of a recent post: “Too much too soon is usually the right response.” It is common knowledge that China announced the virus on 31 December 2019. Less well-known is that Singapore’s first meetings took place the next day, on 1 January, according to Dr Dale Fisher. Hospitals were alerted, their testing capability confirmed, and labs set up. Specialist facilities and training was completed long before. By the time the first case arrived, on 23 January, “Singapore was already on a war footing.”

In stark contrast (albeit with the usual clarity afforded hindsight), other countries triggered pandemic plans but appeared generally to wait for cases to be detected. And, when they did, authorities waited for more cases, to see how serious the problem became. As new evidence emerged, they adjusted plans in response. Some responded rapidly, others less so. The difference is important, as many leaders are finding, increasingly, to their dismay. But, in the language of policy effectiveness and outcomes, whether countries reacted quickly or not, they were all focused on prodigious effort and activity in response to the virus. The virus overtook them all. More precisely, the virus was always ahead; they never caught up.

Instead, focused on outcomes (properly defined, not the common language often used loosely, disconnected from its underpinning science), Singapore ramped up its capabilities three weeks before the first case. The ‘outcomes ethos’ was clear. To achieve key objectives (prevent loss of life and minimize economic impact) responding to the virus is not enough. The best way to achieve such outcomes is not just to respond, but to get ahead of the virus.

Even as countries face what they now know as a devastating global pandemic, that part of Singapore’s lesson still seems missing in many capital cities. Consumed by the detail of Singapore’s initial actions, officials’ plans and actions often reveal mindsets stuck in the ‘evaluate, adjust, and respond’ camp. Just like in January.

Likewise, if Singapore’s early response is overtaken by later events, other countries’ focusing on the details of what Singapore did, rather than why, might write off Singapore as an exemplar — rather than observe its response in a more nuanced way, thereby drawing benefits from the country’s exceptional initial response.

In any event, this difference in approach seems most evident today in debate about the ‘right’ level of testing.

Testing: Missed lesson on verge of repeating?

The most important lesson from Singapore’s initial response was arguably missed in the ‘noise’ of the huge amount of effort and activity in responding to the virus, particularly in dealing with the perceived risk of community transmission: first believed low, then recognized as high.

Early indications suggest that the lesson is again being missed — specifically, in relation to testing — despite many nations suffering the consequence of missing the lesson earlier and, arguably failing to catch-up to the virus by focusing in the wrong place for it, which likely contributed to countries being forced into debilitating lockdowns to slow its spread.

Most countries’ testing regimes for Covid-19 are largely based on existing knowledge about perceived risk factors, such as protocols that test for the disease in cases involving international travel, overt symptoms, and direct contact with known cases.

After all, it sounds fair enough. We need to focus on those we know might have the virus, and can only base testing regimes on existing knowledge, the argument goes. We don’t know the future, so we adapt quickly as we learn more.

That approach is commonplace, and it is of course important to focus on those who might have the virus, yet it characterizes the same ‘chase and catch-up’ mentality when the virus was first announced.

A mindset focused on getting ahead of the virus, rather than chasing it, thinks differently. Rather than a testing regime driven by in-group thinking and tightly controlled ‘on message’ communications based on expert knowledge and assumptions (such as then-current beliefs about international travel and symptoms as primary indicators), a different approach can produce better outcomes.

For example, as soon as cases started to arrive, a cycled series of population samplings — which make no assumptions about whether the virus is mostly associated with travelers, mostly spreading in the community, or transmitted by the fleas of hitherto undiscovered flying camels — might have revealed the truth in time to make a difference. Such an exercise in February may have prompted more countries to refocus efforts to counter community transmission earlier, before initial assumptions were found to be wrong; potentially avoiding the need for some to go into lockdown at all.

Future political historians might judge ‘community transmission’ as a missed opportunity, but that doesn’t matter much now. It is what it is.

However, current decision-making around testing risks being judged more harshly by the cultural pathologists, potentially joining the classic ‘O-ring’ case study in groupthink.

Today, many countries are ramping up testing, for various reasons.

Testing ramps up, but…

Some countries, like South Korea and Viet Nam, used widespread testing (with fast contact tracing and targeted quarantining) to avoid the worst ravages of the disease, and to minimize economic harm from the ‘last resort’ measure of population lockdowns. Nor were they constrained by difficulties claimed by many countries in sourcing test kits, they manufactured testing materials, quickly, cheaply and at scale.

Early exemplars of testing sparked debate about the benefits and feasibility of mass testing. For example, English epidemiologist and statistician Julian Peto reckons that it’s possible to test every person in the UK once a week, with nearly 10 million self-administered postal tests a day, thereby “ending economic disaster for a capital outlay of about £1 a head.” Health economist Cam Donaldson thinks the idea “could be worth exploring” but — with “enormous” labor and postal costs, and the cost of diverting nursing staff — doubts that it is workable.

Unsurprisingly, the low rate of testing in many countries is increasingly criticized. After all, testing delivers information vitally important in responding to the pandemic. It lets people get treatment earlier, helps cut death rates, and reduces the probability of infecting others.

The United Kingdom seeks to “massively ramp up” its testing program and also planned to roll out 3.5 million home antibody tests. However, the tests have not been proven to be sufficiently accurate, and may not be introduced for “at least a month.” Professor Chris Whitty added that such tests were more effective “later” in the epidemic, 3–4 weeks after people were infected. Other European and Asian countries have reportedly bought the tests. They could, potentially, let people know if they’ve had the disease, and, if immune, allow lockdown restrictions to be eased. (There are, however, fears that, if the tests are inaccurate, they may create a false sense of safety, worsening rather than improving matters. The level of immunity is also unclear).

Germany has also ordered antibody tests, and ramped up its existing testing regime, conducting as many as 200,000 tests a day. This should give German authorities vital information to continuously improve capabilities to deal with the virus more effectively than some nations lagging on testing. With lower death rates than many comparable countries, the German strategy of mass testing and tracing seems to be working. (Like Singapore, Germany didn’t just wait for the first case to arrive, according to the New York Times. In mid-January, Charité hospital in Berlin developed a test and posted the formula online. By the time Germany’s first case arrived in February, laboratories across the country had built up a stock of test kits).

Germany’s mass testing increases the number of known cases (unlike other nations testing only symptomatic people, artificially reducing the number of ‘cases’), but the number of known cases is an artificial, and dangerous, metric. In Germany that number is high, as a directed result of widespread testing — which allows earlier treatment and tracing, proactively reduces transmission and deaths, and helps keep Germans safer.

It is unclear if some countries are ramping up testing in response to criticism rather than because they think it will make a difference. Conversely, the same ‘follow the pack’ thinking might cause some countries not to ramp up testing, for the same reason, ie if they believe it will make no difference or is too difficult. In which case, the reasoning goes, they should just keep testing symptomatic people as they present for testing.

However, this form of linear thinking risks missing circumstances when mass testing can make a difference. Like the German example. And, as outlined in this article, like authorities in a small Italian town (noted below), who used mass testing to eradicate Covid-19 — reportedly against the advice of health experts saying that testing beyond symptomatic people was unnecessary according to World Health Organization recommendations.

It is easy to miss unique circumstances when mass testing may be valuable, even if such experts do not currently believe that is generally necessary. Arguably, because it prefers narrow single-discipline thinking over a broader, multi-disciplinary decision-making model. Or, simply in terms of logic, because favoring Peto’s argument (weekly tests for everyone) or Donaldson’s (the cost-benefit of testing 66 million people doesn’t stack up) is a false choice. Both may be right, depending on the circumstances.

For example, the benefits of full-population testing may be valid, but countries with big populations might achieve similar outcomes for their own citizens not by testing everyone, but by testing enough people to resolve the immediate crisis. When the health system can cope, there’s no need to test everyone else, and the scale of testing can be relaxed. That’s what happened in South Korea, and may be equally logical in Germany and the UK.

In such cases, full-population testing may be unnecessary.

In many such counties, other strategies might be more suitable, like Germany’s widespread testing, which both proactively reduces deaths and gains a detailed understanding when the population may gain herd immunity; critical data missing in countries mostly still fixated on testing people with symptoms.

But it leaves an unanswered question. In other countries — such as those with smaller populations, fewer deaths (and less intense pressure to focus every resource to stem mounting death tolls), and the prospect of realizing benefits beyond their own borders — is full-population testing viable?

In the meantime, however, there’s another problem with the type of mass testing currently conducted in many countries.

…the data may be skewed

Whether countries undertake many tests, or only a few, current testing regimes mostly focus on population sub-sections — such as health workers, people recently returned from other countries, contacts of known cases, people with overt symptoms, and those considered most vulnerable, like the elderly and immuno-compromised. Many other groups are missed.

It is important to focus on vulnerable groups (and, according to some experts, may be an optimal strategy in some counties), but it means that answers to some of the most important questions — vitally important in understanding the virus — remain unknown. How does the virus work in asymptomatic people, or those who have had the virus but recovered? Why do some people get seriously ill while others have minor symptoms? These issues and many others are poorly understood.

Researchers will, eventually, find the answers to those questions.

But these aren’t merely theoretical questions. The disease is still ravaging populations. Nearly 1.5 million people are confirmed infected (plus many more, untested and unconfirmed), with more than 83,000 deaths, rising rapidly. Getting answers sooner, when empirical evidence can help stop more cases and deaths, would be invaluable.

However, most countries are focused on resolving the immediate crises facing their own citizens, less concerned for the future impact at a global level.

While understandable, it is chillingly similar to issues presumably facing military leaders in 1918. Whether or not explicit, leaders then had a similar choice, whether to favor the future (quarantine infected soldiers), or meet the immediate needs and mutiny risk of war-weary soldiers. They issued demobilization orders. The rest is history. As it will be, here, either way.

But the generals’ choice was not binary. Quarantining infected soldiers and demobilizing the rest might have better served the immediate needs of infected soldiers and the future impact, possibly stopping or reducing the pandemic’s severity.

Likewise, now. If important new information from a different type of testing regime is capable of improving outcomes in the country undertaking it, and helps the rest of the world combat the virus, it would deliver immediate and future benefits.

But, while testing has dramatically ramped up in recent weeks in many countries, the ‘holy grail’ of testing is missing.

Understandably, testing regimes focus on responding to the virus in ways that help individual countries combat the disease in their own borders. The exigencies of urgently reacting to crisis means that few are bothering much with the niceties of sampling, or testing people without symptoms; in large part, authorities are resolutely focused on the ill and symptomatic.

A different type of testing is prompted by policy effectiveness and outcomes principles, and the leadership to get ahead of the virus, not just respond to it.

Representative sampling, for example, offers the prospect of a substantially better understanding of the virus’ transmission pathways, if done quickly and well (before lockdown hides the reality of who currently has the virus). Full-population testing, however, would deliver a much better understanding of the virus, and a powerful, proven, new way to “control this pandemic,” according to the researchers who conducted one of the first full-population case studies (outlined below).

In the meantime, a recent example of decision-making about the ‘right’ focus for testing — apparently based on then-current expert knowledge rather than a more holistic outcomes-oriented way of thinking — is instructive.

Outcomes science: Looking beyond assumptions and symptoms, enabling objectives

Important decisions about the perceived ‘right’ level of testing appear to have had, or contributed to, monumental consequences.

Until recently, decision-making based on expert advice and ‘current science’ meant that most countries’ testing for Covid-19 focused heavily, sometimes exclusively, on in-bound travelers and people with symptoms. As a result, they gained little understanding how people with few or no symptoms spread the virus, until — literally, by chance — a few cases of community transmission appeared in the tiny pool of testing not looking for such cases.

It is easy, with the clarity of hindsight, to criticize testing regimes not focused on the place where, we now know, most of the spread probably occurred in many countries.

Worse, skewed testing likely engendered a feeling of safety, allowing the virus to spread more quickly. Experts reporting “no evidence of community transmission” may have inadvertently contributed to lax physical distancing and massed crowds of shoppers stockpiling before lockdowns, exacerbating the problem.

After all, limited testing regimes, largely ignoring asymptomatic community transmission, reflected the dominant narrative. Even as late as mid-late February, an influential WHO report declared that it was thought to be “relatively rare” for people with no symptoms to transmit the disease. At the time, the focus on travelers and symptoms was the perceived ‘best practice,’ expert-driven, scientific, way to combat Covid-19.

Except that it wasn’t. At least in the sense that it may have reflected the dominant scientific discipline, but not ‘science’ generally, viewed holistically across other decision-making disciplines.

Nor did it reflect Singapore’s initial ‘get ahead of the virus’ mindset. As Dr Fisher described Singapore’s “liberal” testing regime:

We realized that if we only looked at travelers from China then we would only find travelers from China.

Reducing the risk of focusing on cases that might represent only the tip of the iceberg, a key part of Singapore’s response involved proactively “identifying cases and early diagnosis.”

Rather than base testing on the medical science of ‘what we currently know’ about the virus, outcomes-oriented decision-making science recommends that public health professionals consider testing criteria based on ‘what we want to achieve.’

Often, this will be the same. But not always, as the initial focus of testing suggests.

Similar issues appear in the current debate about mass testing.

Optimal testing regime, for optimal outcomes

Outcomes science is of course cognizant of the perceived state of existing knowledge, and defers to medical expertise, but endeavors not to limit or constrain possible outcomes within the bounds of perceived ‘truths’.

For example, if the primary policy objective involves maximizing health outcomes and minimizing economic damage, it means that we need to know how the virus operates, but without assumptions about how we think it operates. That is because existing knowledge might be true (young people are less susceptible to the disease), wrong (asymptomatic transmission is rare), or misleading (if, for example, it is found that young people are super-transmitters).

In Singapore-parlance, it involves using the science, not being constrained by current scientific beliefs. So, rather than limiting testing to standardized norms appropriate for responding to the virus, testing should be broadened to get ahead of the virus.

This suggests a multi-tiered testing regimen.

1. Medically-oriented. This involves testing symptomatic patients, focusing on the most vulnerable, and treating everyone who needs it. This is a standard medical response, and appears widespread. It is largely unconcerned with the niceties of scientific sampling, resolutely focused on treating patients, and trying to “flatten the curve” of the pandemic to reduce the flow of patients to manageable levels.
2. Outcomes-oriented — where full population testing not feasible. Here, a range of complementary testing strategies may be needed to reduce deaths and economic damage, including widespread testing, as noted above. Random, representative sampling also gives a good understanding of transmission pathways. Even if herd immunity is not the strategy, both also give detailed information about when that desirable side effect is reached, which virtually stops viral transmission before the full population is immune or a vaccine is developed. In the meantime, rather than common “flattening the curve” policies — which may only defer deaths, ineffectively fight the contagion and cause economic collapse — resources might best focus on proactively testing and protecting the vulnerable. As Dr David Katz adds, “this would allow most of society to return to life as usual, and perhaps prevent vast segments of the economy from collapsing.”
3. Outcomes-oriented — where full-population testing feasible. With objectives to optimize overall population health and economic outcomes, the optimal testing regime should also look across all possible transmission pathways, unconstrained by assumptions. In smaller countries with adequate resources, the additional benefits over and above representative sampling may tend towards full-population testing. As well as giving a more complete understanding of the virus, full-population testing also enables pandemic control, as Italian researchers found, outlined below.

Full-population testing case studies

Screening an entire population has only been done a few times, but has already produced vitally important information.

Testing is still underway on 4,865 crew members of the US nuclear aircraft carrier USS Theodore Roosevelt, so initial results are inconclusive. On the Diamond Princess, however, a cruise ship with 3,711 passengers, everyone was tested, sometimes twice. This revealed shockingly relevant information about the disease. Researchers found that as many as 18% (or more) people with the disease show no symptoms at all. (Other studies also found asymptomatic transmission, of varying amounts, with the CDC later suggesting it might be as high as 25%). This was a significant finding. From a belief that asymptomatic transmission was “rare”, it is now believed that as many as 60% (or more) of people with Covid-19 show mild or no symptoms, many silently passing it on to others without knowing they have it.

If that information was known earlier, or — critically, not assumed in the first place, with neutral population sampling potentially revealing the truth earlier — more serious attention would have been given to stemming community transmission earlier, rather than waiting to see if it appeared in tracing contacts associated with the primary focus groups (international travelers and those with symptoms).

It is currently hard to know, but seems a reasonable hypothesis that — if decision-makers pivoted to the risk of community transmission earlier — more countries might have been able to avoid economically damaging lockdowns.

In the meantime, the current furor over the ‘right’ level of testing offers another opportunity for political leaders to choose between responsive decision-making or the bolder ‘get ahead of the virus’ form of leadership initially modeled by Singapore. Either way, such decisions will affect, possibly profoundly, the citizens and economies of all nations affected by Covid-19.

From an overall outcomes perspective, it seems difficult to overstate the significance of gaining a better understanding of the virus, whether by sampling or full-population testing.

Why population testing matters

Writing in the Guardian, Andrea Cristani (professor of microbiology at the University of Padua) and Antonio Cassone (former director of the department of infectious diseases at the Italian Institute of Health) described the results of a case study in the Italian town of Vò Euganeo, population 3,300 (and home to the country’s first death). The town was locked down and all residents were tested for the virus, including those with no symptoms. Three percent of the population were infected, but as many as a half of those infected showed no symptoms. After several rounds of testing, within a few weeks the virus was eradicated.

The regional governor, Luca Zaia, declaring Vò “the healthiest place in Italy” said:

We tested everyone, even if the ‘experts’ told us this was a mistake: 3000 tests. We found [89] positives, who we isolated for 14 days, and after that six of them were still positive. And that is how we ended it.

Mass testing eradicated coronavirus from Vò, according to the researchers, “achieving a 100% recovery rate for those previously infected while recording no further cases of transmission.”

They also made an “interesting finding”:

At the time the first symptomatic case was diagnosed, a significant proportion of the population, about 3%, had already been infected — yet most of them were completely asymptomatic. Our study established a valuable principle: testing of all citizens, whether or not they have symptoms, provides a way to control this pandemic.

The researchers believe that it’s too late to adopt this approach in places where “infections are out of control.” Elsewhere, it remains an option.

Moreover, the general approach in Italy, said the researchers, like many other countries, remains only to test people who present with disease symptoms. This means that people who haven’t asked for medical attention are seldom tested. But, added the researchers:

…asymptomatic or quasi-symptomatic subjects represent a good 70% of all virus-infected people and, still worse, an unknown, yet impossible to ignore portion of them can transmit the virus to others. Full testing would give us a clearer picture of how many people actually have the virus, and how many pass it on.

Without wider testing, authorities won’t know how many people are infected and spreading the disease. Nor how many have already had the disease, and may have some immunity. Like Fergus Walsh, the BBC’s medical correspondent, surprised to learn that he may have previously contracted Covid-19, despite no symptoms of coronavirus.

Widescale population testing — ie screening to check who has the virus, as well as antibody tests to see who’s had it and recovered, offers a research pool of all subjects including people without the virus, and everyone who currently has or has previously it.

Antibody tests are not yet regarded reasonably reliable, according to strict medical standards, but, in practical terms, cycled testing, say every 7-10 days, with fast contact tracing, can mitigate and soon virtually eliminate the risk of false-negative and fast-positive findings.

When countries now in lockdown manage to get major outbreaks under control, data from all-population testing would be immensely valuable in global efforts to combat Covid-19. It would also help countries like Sweden design their own testing programs, where it is now arguably “too late for a lockdown anyway,” according to BjÜrn Olsen, a professor of infectious medicine. He now advocates “extensive testing and directed quarantines rather than…shutting borders and schools.”

Generally speaking, as the Italian researchers found, to really understand how the virus works — and to shape the most effective strategies to mitigate, contain, and eliminate it — we need to know who’s already contracted the disease, including those with mild or no symptoms, as well as those with more serious symptoms already ‘in the system.’

We also need to know if people who have had the disease and recovered are immune, any factors that might affect immunity, and risk factors likely to lead to more, and less, severe symptoms, beyond simplistic age and immuno-compromised information already known — but even in that regard, current knowledge is based on limited data.

For example, children may be less susceptible to serious symptoms, but are they more efficient carriers, potentially passing it on to more people? To what extent do multiple doses of the virus cause more serious disease?

Currently, most strategies to combat Covid-19 are based on limited data, assumptions, and expert guesswork.

Better knowledge, based on extensive, comprehensive, reliable, empirical data, would help scientists devise more effective strategies to reduce transmission rates, mitigate the severity of infections, cut the number of deaths, improve screening capabilities, and more quickly develop a vaccine.

Testing vitally important

Germany is widely known to have massively ramped up testing. With nearly 83 million inhabitants, it would take 14 months to test everyone. But tests aren’t perfect, and targeted and multiple tests, and testing cycles, are needed, so it will take longer to test everyone, and longer still for definitive results.

But, although testing everyone might help the world in the near future, it wouldn’t necessarily help German authorities now. They’ll likely have the outbreak under control (in terms of tier 1 testing) long before a full-population testing program finishes.

This suggests that, in big countries, full-population testing may not be an effective pandemic control mechanism like it was in a small village. People who test positive can be treated or quarantined, and those who test negative can be released, allowing businesses to restart, but it would be difficult to devise a fair way to test and release from quarantine some people now while asking others to wait up to 14 months. Moreover, tests aren’t perfect, and mass testing as a pandemic control mechanism needs at least several cycles. This tends to indicate a tier 2 rather than a tier 3 response in such countries.

It is, therefore, understandable why countries’ testing regimes respond to their immediate problems, but that doesn’t make tomorrow’s problems go away. When some countries slow transmission rates enough to re-open their economies, and others manage to stop escalating deaths, they will still have only the same tools helping authorities respond to the virus now. Another tool, helping all nations get ahead of the virus, would be invaluable.

Collaborative leadership for humanity

Island nations with relatively small populations, excellent health systems, a world-class scientific community, well-functioning governments, and access to considerable resources, have unique characteristics that could help unlock new ways to combat the disease in their own country, potentially allowing earlier release from the prospect of months’ of lockdown, or reduce the need for pulsed lockdowns, without compromising safety. Full-population testing also offers valuable data for other nations.

Testing at the scale of populations may be prohibitively difficult in large populations, and perhaps only a handful of smaller countries could do it well. Whether any choose to do so probably depends less on geography than vision, strategy, implementation, resources, and political will.

In that latter regard, I humbly offer the following letters to the leaders of two such countries that could, I believe, make a real difference, benefiting their citizens, and the world.

Unfortunately, neither country has likely ordered, or manufactured (despite the “how to” readily accessible, as noted above) enough testing kits to make it happen. Simple lack of foresight to get ahead of current logistical problems might negate the opportunity to get ahead of the virus. The United States or European Union could help make it happen, yet may be too distracted with immediate problems. China, Viet Nam, and/or Jack Ma might be ready, able and willing to help. Either way, it might need the combined foresight and political will of at least several nations, perhaps more, to help their own citizens, and the world.

That is because the difference in outcomes around the world is not just down to the virus. It operates the same way in New Zealand, Singapore and South Korea as it does in Italy, Spain and the United States. Beyond a theoretical baseline no-one could have avoided, more deaths in some countries than others, and the global economic impact, is mostly down to the management, and mismanagement, of the threat when it first became apparent.

Likewise, today, as countries quell transmission rates with the blunt instrument of lockdowns, get on top of mounting deaths, and develop plans to come out of lockdown.

Nor is leadership alone sufficient to meet the collective threat. In a globalized world, the public health threat remains for all countries until the virus has been contained everywhere. The economic impact is also felt everywhere.

However, like the millions of citizens who put aside what they thought divided them — to help neighbours, and complete strangers, get through the biggest challenge in most people’s lifetimes — collaborative leadership in shared humanity may be the difference between some nations coming out of this relatively unscathed (at least from a public health perspective), and all countries being in a better position to relieve the pressure on health systems, reopen economies, and refocus collective effort for a vaccine.

For many countries, tier 2 testing may be all that is practically available or optimal for their populations, but for a few countries in a uniquely privileged position — if they can but see it and make it happen — as economist Alex Erskine summarized this paper:

In the absence of an effective vaccine, effective quarantining…and systematic periodic whole-of-population testing will be the most healthy way forward.

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Update 26 & 29 April 2020

“You really don’t want to go to the quarantine policy unless you have to,” said James Bullard, president of the Federal Reserve Bank of St. Louis. “The quarantine was maybe the right response initially [but society shouldn’t] think in terms of rolling quarantines.” He compared making widespread tests available to providing common goods, like eggs or cups of coffee. “People say it can’t be done or we don’t have enough resources [but] you really want to ramp that up at all costs…”

UCSF researchers conducting all-population testing in urban and rural settings, Covid-19 and antibody tests

Thanks jen segal

Los Angeles offers free coronavirus testing to all residents. Mayor Eric Garcetti said that getting tested was “a really important step” to prepare for Governor Gavin Newsom reopening the state. Priority will still be given to health care employees, other workers who interact with the public and people with symptoms but the mayor said that asymptomatic people can get tested, including those who want multiple tests over weeks or months.

Viet Nam’s testing regime is producing promising results, and has also produced so many cheap testing kits that it exports them to other countries.

For an economic perspective of New Zealand’s seemingly health-centric approach, but which ironically locks in slightly worse health outcomes, and much worse economic outcomes, the author’s comments on Sir Bob Jones’ blog:

Also in this series