How to End a Pandemic

post by MikkW (mikkel-wilson) · 2022-01-03T20:26:07.009Z · LW · GW · 27 comments

Contents

    Our toolbox
    Vaccine-only zones / cities
    More lightweight regulation of medicine, particularly vaccines
  Conclusion
None
27 comments

Disclaimer: I am not an epidemiologist, and my knowledge of the field is limited to what I have learned from the following experiences: 1) being a person who has lived through 2 years of a pandemic 2) having played a decent amount of Plague, Inc. (for whatever that's worth) 3) having taken a microbiology class when I was in college. So what I say should be taken in the sprit of proposing potential solutions, not as an assertion of what we know will work. This is babble, not prune [LW · GW].

So, we're in the middle of a pandemic. COVID-19 has been causing problems for 2 years, and the US (like many countries) is now seeing the largest number of daily cases that it's ever experienced (!). The question I want to explore is: What can we do to make this pandemic end? A related question asks how we can eradicate other viruses that are causing problems, including flu and the common cold.

Some might hope (as I've heard some suggest) that with Omicron swiftly sweeping through swathes of people, a very large fraction (90%+) will be infected with the virus, and some of those people will die, but the remainder will become immune, thereby leaving COVID-19 no more room to propagate. One might hope this ends the pandemic globally over a period no longer than 90 days.

Indeed, we should expect that this very dynamic will cause Omicron to spell out its own end, as well as the end of the Delta variant and the original variant that started this mess. But I would also remind you that there are many, many particles of Coronavirus around the world, and many of the particles carry a wide variety of mutations that are seen in neither Omicron, Delta, nor the original variant. In my estimation, it is almost inevitable that one of those variations will provide enough resistance to immunity to allow it to cause problems long after the Omicron wave is over- and I don't expect that that variation would be the last variant of Covid we face, either.

But who knows, it could be that I'm not right on that. If Omicron really does spell out the end of the Covid-19 pandemic, then consider the rest of this post to be a discussion of what we might do if another pandemic happens down the road (which I hear experts assign too high of a probability to for my comfort).

Our toolbox

We have various tools in our toolbox: Masks and other protective equipment; lockdowns; quarantines; border closures; But the most powerful tool in our toolbox are vaccines. With vaccines, a person can both cut down dramatically on the probability that they get infected by a virus, and reduce the severity of the disease they get if they do get infected (and a corollary to this, is that they are far less likely to infect other people when vaccinated). The Moderna vaccine (which is what is providing me with protection) was developed over the course of 2 days in January 2020, before the United States even entered its first lockdown, though it took several months for it to be approved for use in the USA (and basically everywhere else). I mention this to illustrate that not only are vaccines effective, being able to effectively shut down a virus if enough people receive them (though that part has proven to not be without issue), they can also be very rapidly developed and adjusted to respond when new versions of a virus emerge.

While we should be willing to use all tools in our toolbox, not just vaccines, to respond to changing situations, we should rely on vaccines as our main weapon against the pandemic, and deploy up-to-date vaccines as quickly as possible, when considerations of safety and public willingness allow for it. This is because vaccines are the only tool we have that can stop a virus in its tracks without causing undue damage to human productivity and human happiness (note that while vaccinated people can be infected, and can even infect others, when there's a low enough density of non-vaccinated people in a given population, the reproduction rate will fall enough to make the virus disappear instead of growing exponentially).

But when I say "when considerations of safety and public willingness allow for it", that should not be taken lightly, since we have so far been unable to navigate matters of safety and public willingness to a degree necessary to allow us to effectively use vaccines to defeat the virus. Some specific cases where we have so far faced issues:

1) Verifying and certifying that a vaccine is safe has taken orders of magnitude longer than actually developing the vaccine

2) Even once a vaccine is certified to be sufficiently safe, substantial numbers of people feel uncomfortable being vaccinated. This may be to lack of trust in the producers of the vaccine (which can be understandable), or due to their standards of safety being different from the standards of safety of society at large, or due to misinformation (which is unfortunate, and a signal that we need to improve society's ability to handle misinformation while respecting people's freedom of speech and thought, but it's hard to blame too heavily the victims of misinformation when it's so endemic).

This presents an interesting dilemma, where we both find it desirable for people to be able to live in an environment devoid of non-vaccinated people if they so desire, but where we also should be somewhat uncomfortable with forcing people to be vaccinated, because forcing things on people that are known to have impacts on health, and where people don't trust that the thing they are being given is what they're told it is, is a thing that we should generally be uncomfortable with. (To be clear, I'm not saying that we can't or shouldn't do this. Sometimes, especially in matters where people's life or death depends on other people's choices - like in war, and like in a pandemic - society needs to be able to make hard choices for other people. But I am saying we should be *uncomfortable* if we do find ourselves in a position of having to make that decision - and while I'm strongly pro-vaccine, I will also note that the lethality of Covid-19 is not so high that the case is cut-and-dry)

2a) People who want to be vaccinated, and who would prefer to not be around non-vaccinated people, live in the same cities and regions as non-vaccinated people who feel uncomfortable with being vaccinated.

3) Even once a vaccine has been approved, it is only approved according to a specific dose regiment - doses must be taken with specified intervals between them, and the dose received must be a specific amount - no more, and no less, than what is specified. This has proven particularly problematic, since the size of the dose specified was too large, which caused two problems: the short-term issue is that we were wasting vaccine when we were constrained by supply (both supply in the US, and globally), causing many people to be unvaccinated unnecessarily for months, and the issue that is still a problem is that the reactions people's body had to the vaccine were noticeable, decreasing people's willingness to get vaccinated, while a smaller dose would have provided similar protection without harming people's health.

To address these concerns, I propose the following:

Vaccine-only zones / cities

To address problem 2), there should be areas that are designated as vaccine-only, where people should only be allowed to enter or live in the area if they are vaccinated (this does mean that a perimeter would have to be set up around the zone, to prevent the entry of non-vaccinated people; people who are unable to be vaccinated for recognized legitimate health reasons would be exempted, as long as the density of exempted residents doesn't exceed a certain threshold). This would allow people, especially people who are vulnerable, to be able to live in an environment where everybody is vaccinated, while leaving people the freedom to decline the vaccine without burdening those who value herd immunity. Ideally, the zones should be established in sparsely-populated areas close to established cities, to prevent there being problems with having to relocate people currently living in the area who don't wish to be vaccinated - if the zone is sufficiently sparsely populated, an exemption can even be granted to the prior residents, without unduly harming people's protections.

The zone should become self-sufficient to allow people to live and work and do everyday things while staying surrounded by vaccinated people, but residents would be able to come and go as they see fit (if someone does get infected, herd immunity would prevent it from becoming a big problem in the community). Residents in these zones, by choosing to live there, would consent to follow the guidance of the zone leadership as to which vaccines are necessary (and safe) at any given point in time to address the shifting diversity of variants.

More lightweight regulation of medicine, particularly vaccines

The reason why the FDA exists is to make sure that people don't buy stuff they think is medicine which will help them, only to get hurt by what they take. This is a good cause, and it's important for people to be able to buy medicine without having to doubt if they've bought something that's actually going to be bad for them. But, it's also expensive and slow to move medicine through the FDA process, and this often kills people who have problems that can be solved with medicine that has been shown to work, but not up to the very high bar that the FDA sets (and we can't just say we'll lower the bar, because then people wouldn't be able to trust that what they're buying is truly high-quality).

The right approach to this, is to recognize that the question of whether a medicine should be legal isn't a binary question. The FDA shouldn't be forced to say that either a medicine is 100% safe and proven to be unproblematic, or else say that it's dangerous and illegal. If I walk into my neighborhood pharmacy store, and grab some sleep medicine off the shelf, I want to be able to trust that what I'm buying will be unproblematic. But if I need something that has preliminary studies suggesting that it could help me, but is far from being studied well enough to be known to be unproblematic, and there is no better-known substance that can solve my problem, I should be able to ask the pharmacist to escort me into a dark room in the back of the shop, where after having me verbally declare that I know that what I want to buy isn't proven to be safe, and may cause me problems, the pharmacist can sell me what I need.

There would be multiple tiers, ranging from completely untested, to only weakly tested, to having a moderate evidence base, to having a strong-but-not perfect evidence base, to being highly vetted, with each tier indicating an increased ease of being able to obtain the product.

Of course vaccines would fall under this: When new variants of a vaccine are developed, and initial trials show no obvious problems, people should be able to talk to their pharmacists, and after declaring that they understand the product isn't yet vetted to a high standard, be able to obtain the vaccine; while the broader population will wait to see it be vetted to a higher standard. This would also give individuals the ability to use smaller doses of vaccines, or to choose their own vaccination schedule, if they have reason to believe that doing it differently will be in their best interests.

Combining this with my earlier proposal, different vaccine-free zones may signal that they will require vaccines that have been vetted to different degrees: Many zones may only mandate vaccines after they have been thoroughly vetted to the highest standard, others may simply require results that strongly indicate it's safe, and other zones (whose residents consent to such an approach) may even mandate vaccines as soon as it's only moderately verified to be safe. People would be able to pick which type of zone they chose to live in, and thereby decide how they balance the competing risks of vulnerability to variants with immunity escape vs. being affected by unknown side-effects of partially-verified medicine.

Ultimately, this will give each zone the ability to pursue a vaccination policy that it expects will best be able to minimize the spread of the virus while allowing people to live life normally.

Conclusion

While these proposals would not end the pandemic for everybody, they would allow many people to be able to live relatively normal (by pre-pandemic standards) lives insulated from the dangers of the virus. As time goes on, if these proposals succeed in helping people return to pre-pandemic lifestyles safely, the number of people living in such vaccine-only zones will increase, until only those who are the absolutely most uncomfortable with vaccinations would live in non-vaccine-only zones (which should be their right to choose). When that happens, the pandemic would be essentially over for most people.

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