COVID-19: What Next?

John Helliwell is Senior Fellow of the Canadian Institute for Advanced Research (CIFAR) and Co-Director of CIFAR’s program on “Social Interactions, Identity and Well-Being.” John is also Professor Emeritus of Economics at the University of British Columbia, a Member of the National Statistics Council, a Research Associate of the National Bureau of Economic Research, and Editor of the World Happiness Report.

In this special feature, John shares what needs to come next in our COVID-19 recovery and how we need to find an exit plan that can restore production and jobs while protecting health and the social fabric.

The Covid-19 pandemic struck with unprecedented speed and power, threatening the three main pillars of support for well-being: health, employment and social support. It started with the infection, of course, followed by drops in production and increases in physical separation flowing from health policy actions taken to flatten the curve. The timing and effectiveness of these curve-flattening attempts have varied greatly among communities and countries. Whatever their success in flattening the curve, all communities now face the need to find a plan to restart production and restore daily life without triggering fresh escalation of infections and deaths.

The design of an appropriate strategy for ending isolation requires a broadening of epidemiology to consider the intersecting vectors of infection, employment and social connections. For economics and the policy sciences more generally, it requires alternative policies to be evaluated by a broader cost/benefit analysis that gives all aspects of well-being their due weight. This broader analysis has been enabled by making use of experiments and surveys based on how people evaluate the quality of their lives. Researchers have learned how to measure and compare the benefits of health, income and employment, social connections, trust, generosity and freedom, to list only the key elements used to explain differences across the world and over time of how people rate their lives. Analysts all over the world are now sharpening these tools to help in the design of the next steps in pandemic response. But this broader epidemiology is facing the same problems as the more narrowly focused tools used to deal more separately with epidemics of disease, production and social connections. COVID-19 is a new and highly infectious virus that has swept the world at a pace and scale to over-power health care systems, decimate production and employment and re-write the norms of social behavior to an extent that is globally unprecedented. It is correspondingly difficult to estimate how these various changes have affected the overall well-being of those both sick and well, connected or alone, innovating or idle in forced isolation. As in previous times of crisis, this pandemic has brought out the best in people while exposing the worst. As also seen previously after earthquakes and tsunamis, people are on average pleasantly surprised by the selfless generosity of others, and cherish the chance to regularly cheer for the front-line health care workers routinely risking their lives to save others.

In many countries, the strategy for re-starting is seen as a trade-off between getting the economy going again and the risk of re-igniting the pace of infection. What if it were possible to find policy options that would improve one or both of these goals without risking the other, while still maintaining the sense of trust and common purpose that has made the shut-down effective in many jurisdictions? The possible existence of such win-win policy choices lessens the need for trading off someone’s job against someone else’s life, and is thus especially worth some careful searching. 

Widespread Testing Saves Lives and Jobs

The most obvious win-win policy choice is the use of widespread testing to identify and isolate asymptomatic and pre-symptomatic carriers, and using serological testing to identify those who have had the virus and have thereby acquired some degree of immunity. The benefits of widespread testing, accompanied by isolation of virus carriers, are evident from the international comparative data (Sachs 2020) showing East Asian countries to have had much lower death rates and lesser drops in economic activity via a combination of case tracing, testing, and isolation. For countries outside China, tracing of incoming identified cases and their contacts was a natural first step. But it failed to avoid subsequent local transmission because of undiscovered asymptomatic and pre-symptomatic carriers, sometimes exacerbated by being late to start monitoring incoming passengers, originally from China, and later from other countries in which community transmission was becoming widespread. Earlier appreciation of the extent of transmission from asymptomatic and pre-symptomatic carriers would have led to earlier adoption of widespread testing and hence limited the subsequent community spread. Countries then realized, at different speeds, the resulting need for physical distancing and travel restrictions to limit community spread. Although the current situation has to be accepted for what it is, the expensively learned lessons should not be forgotten. Instead that experience can and should be used to inform a lower-risk and better managed exit from lockdown.

Creating COVID-free Living Spaces, Jobs and Communities

The essential ingredients for successful learning about better ways to end the medical time-out would seem to be three. 

First, the health authorities need a much deeper knowledge of the distribution and pace of infections, and matching community-level estimates of who has been infected and who remains at risk. It is also important to know the current state of health, including co-morbidities and resistance to infection of both groups. The fastest way to kick-start the filling of that knowledge gap is to exploit the symptom tracker surveys and apps already in use by millions of Canadians. The coverage of information provided needs to be extended to include the reporting of previous infection, current state of health, the date and nature of any COVID-19 testing, and ideally something on current circumstances of life, including income, employment, and the extent to which people have been able to exploit on-line connections to maintain satisfactory social connections and productive employment.

Second, there needs to be effective universal testing within each space or community that is a candidate COVID-free zone, with those identified as asymptomatic or pre-symptomatic carriers put in stringent isolation. Testing frameworks that cover representative samples of the target population are of vital importance for estimating the still largely unknown frequency of asymptomatic infections, since that fraction strongly affects the extent to which any lockdown of social and economic activities affects the number of current and future serious and fatal cases before the epidemic runs its course (Stock 2020). Candidate populations for COVID-free status require universal testing, so that asymptomatic and pre-symptomatic individuals are put into isolation until their infections have resolved.

Third, there needs to be similar testing for all those subsequently entering the proposed COVID-free space or community, to ensure that no new vector of infection is allowed to enter.

To understand the virus and the likely transmission effects of lockdown activities requires the measurement of the antibodies present in all those who have been infected, whether or not they have ever shown symptoms. If the population share of the asymptomatic is high compared to the symptomatic share, there is a corresponding drop in the number of future serious cases. It also advances the date at which the population as a whole achieves immunity

When and How to Start?

The time to start was February. Limitations on the availability of tests should have been addressed earlier, as soon as the extent of asymptomatic and pre-symptomatic transmission became apparent. Starting now, with testing more available but still limited, the choice of places to start should consider the scale of the possible gains as well as the ease with which entry to the space can be readily monitored. On both these grounds, hospitals, prisons and elder-care facilities are obvious first targets.  Testing of all those with access to the space is crucial, and still not standard practice even in these spaces. Once the risk has been reduced for front-line caregivers and those living in restricted spaces, what might be the targets most likely to combine lives saved, jobs maintained or restored, and in-person social contacts re-established?

To proceed on an experimental basis, acquiring knowledge along the way, would seem both prudent and in line with the currently still-limited availability of rapid and reliable antibody tests. Key facilities and parts of the physical and institutional infrastructure are natural targets: powerplants, communications facilities, physical first responders, and key elements of the transportation system.  

Two other criteria for easy creation of COVID-free zones are geographic separation and limited points of access, both of which make it easier to monitor individuals entering an established safe space. Indigenous communities are obvious candidates. All communities with limited road access also facilitate monitoring. These would include islands and remote towns. From an economic perspective, resource-based communities largely employing local residents, or where incoming workers can be monitored effectively, are natural candidates. These might include mining and smelting, forestry and lumber, agriculture. If local communities had the capacity to test and monitor, then application might quickly become more general. This might even extend to tourist facilities once the accommodation needs have been met for those requiring long term recuperation from COVID-related illness.

Each community and industry should be invited to design and develop its own strategy for creating safe spaces for renewed economic activity and continued shelter for those still at risk. Starting with the creation of safe spaces, monitored by universal testing, would seem the most effective way to start the transition back to normalcy. It gains a lot of its attraction and power for precisely the same reason that lockdown became necessary in the first place – the large number of asymptomatic carriers who have now acquired antibodies, are no longer infectious, and are ready and willing to go back to work, play, and community life.

How might the increased use of testing to create COVID-free zones lessen the economic and social damage of COVID-19 and ease the transition back to a fully functioning economy in a healthy and socially connected society? 

Here are some possible ways: 

1. By making hospitals COVID-free (except for separately-managed COVID patients) safe spaces will save drains on medical personnel, hence raising the capacity of the health-care system to avoid overload (and thereby encouraging earlier opening).
2. The broader testing strategy applied to focal points of infrastructure will ensure continuity of the supply lines required for start-up (and even lockdown)
3. The selective approach can permit raising production and employment far sooner than any feasible date for the higher-risk fast opening.
4. The epidemiological data (especially concerning the proportions of asymptomatic) provided by blanket testing will reduce the uncertainty about the risks of re-ignition.
5. The testing will increase the known pool of those who have recovered from the infected. There is likely to be a large number of previously undiscovered asymptomatic cases now having significant resistance to reinfection. Widespread testing would permit them to be discovered and freed, to an extent determined by the still-unknown extent of immunity provided by previous infection.
6. The efficiency with which full testing plus controls can be applied to resource and other remote communities with high value-added per employee means that early economic gains can come with no medical risk, and indeed will through increasing the evidence base accelerate the likely date and reduce the attendant risks of a more universal economic opening. 
7. The existence of a thought-through strategy for phased re-opening will help maintain citizen trust in health experts and the government.
8. The fact that vulnerable populations, e.g. those in hospitals, prisons, elder-care and homeless, are being removed from their current excessively risky situations will increase the possibilities for further openings after these hardest-hit areas are being given a COVID-free environment. 
9. The existence and hoped-for success of the phased and experimental opening of plants and communities are likely to increase worker and business confidence that there is light at the end of the tunnel, and a sound basis for future employment and investment.
10. Finally, this evidence that plans are being developed that will improve health outcomes and economic activity will help to counter beliefs that it is necessary to choose between good health and a functioning economy. 

Are There Still Better Strategies for the End-Game?

There is an extension to the above strategy, perhaps best called “Fighting fire with fire: using COVID to end the scourge of COVID”.

It has been argued in the previous section that exit from the lockdown can be helped by creating COVID-free zones to protect the vulnerable and to maintain key productive services. But is there not an even more successful and productive second half – a COVID end-game – that would make more effective use of the cadre of those who have recovered from COVID and are ready to restart their lives and the economy? The idea would be to have ventures that are peopled by those who have acquired antibodies through having had COVID. For each elder care facility that is using testing to keep COVID out, there could be one, or part of one, for COVID veterans, both staff and residents. In those facilities there would be no need for physical distancing, and also-immune family could visit. At the other end of the spectrum there could be re-opened resorts, Club Meds and cruise ships to the extent that immunity can be established. 

There are current plans for COVID tracker apps that show for each individual a red or a green light, according to whether they test positive or negative for the COVID virus. Why not add a yellow light, and make the green light a passport to freedom? The green light would now appear only for those who have sufficient antibodies to be able to do anything, the red light would be, as now, for those with the virus currently active, and the yellow light would be for those who are currently COVID-free but have not acquired protective antibodies. Perhaps flashing green would be better, since the degree of immunity provided by past infections still remains to be discovered.

The argument above uses examples of hospitals and elder care facilities, but it is equally applicable to factories, mines, or restaurants. For the coming stages of the epidemic, those with the green light on their apps would be safer anywhere. This strategy relies on fast and reliable tests for antibodies, and some assurance that reinfections are very unlikely. Is it not time to think more positively about what can be done to improve the current lives of COVID survivors, giving them more effective roles in helping themselves and others to build a better post-lockdown society?

Inequality and the Social Fabric

This paper started with the proposition that the advantages and disadvantages of alternative plans for managing the transition from pandemic lockdown should be assessed in terms of their effects on the average levels and distribution of well-being. The particular suggestions made here were chosen in the hope that they could lessen the emerging tensions between those wishing to open the streets and the economy right away and those wishing to keep restrictions in place longer to minimize the loss of life. Underlying that tension is the epidemiological reality that flattening the curve may, if done well, avoid overwhelming the health care system, while also delaying the time when the population has achieved immunity. For a virus as silently communicable and as deadly as COVID-19, the policy responses in most countries have eventually evolved, whether through advance thinking or painful experience, to include lockdowns so restrictive as to be economically and socially unsustainable in the longer term. In broad terms, the tradeoffs that appear in a well-being calculus show that removing restrictions more quickly combines faster restoration of economic and social activity with an attendant greater risk of COVID-19 deaths. The purpose of this note is to suggest that the ways in which the re-opening is organized offer potential for saving lives and the economy, while maintaining the high degree of social solidarity that has characterized the lockdown in its early weeks in many countries. I have advocated much expanded testing for both the presence of the active virus and of the prevalence of antibodies in the population. Both sorts of information reduce the health risks of achieving any chosen pace of reopening. Testing of both types is required to support the creation of activities or spaces where normal life can be restored quickly at low risk. 

What are the effects of COVID-19, and of alternative plans for re-opening, on inequality? Inequality affects the well-being of all, and not just those who are suffering. The inequality that matters most to people is that of well-being as a whole, which of course depends not just on the distribution of income, employment and health, but on the quality of the social environment in which people live. Furthermore, the effects of inequality on the disadvantaged, and on the society as a whole are less in communities where people trust each other, and their governments, more highly. COVID-19 has been a great source of inequality, not just in its immediate choice of victims, but in how unequally the costs of lockdown are spread among the population. In broad terms, the prevalence of population spread via asymptomatic or pre-symptomatic carriers has posed especially great risks for caregivers in the front lines, as well as those who are already without good health, freedom and adequate food and housing. It is no accident, although it might have been better foreseen and averted, that the toll of COVID-19 has been so great in elder care facilities and prisons and among the homeless and poorly housed. A central aim of any strategy for dealing with the disease should be to improve the incidence and reduce the pains of such inequalities.

The proposals made here to focus urgently on creating COVID-free zones in the most affected communities would help to reduce the existing inequalities of incidence, with the major gains being received by those already most in need. The choice of which activities and locations beyond those starting points would be based on both costs of establishing a secure perimeter and risks should COVID arrive. Indigenous and far-flung northern communities are strong candidates on both grounds, even if complicated by overlapping federal, provincial and Indigenous jurisdictions. Applications to larger communities and industries presumably would require local leadership and willingness to do what is required to support a safer end to the lockdown. It is not clear whether there would be too many or too few towns wishing to be leaders in these experimental lockdown reductions. The inequality effects of these community-level applications are correspondingly difficult to predict. 

The use of widespread antibody tests to better measure the incidence and stage of COVID-19 prevalence is obviously a key element in decisions about how, when and where to loosen restrictions. It would also accelerate the important process of learning about the nature of the immunity provided by previous COVID infection. If this immunity should prove to be substantial, then it provides a powerful resource to speed and aid life under lockdown and during the transition. History has provided examples of where the advantages of immunity have been used to increase inequalities. For example, Olivarius (2019) shows how immunity to yellow fever was used in the ante-bellum south of the United States to add to the wealth of the owners of the surviving slaves, whose value was correspondingly increased, and to reduce the competition from still-at-risk immigrants. In 21^st century democracies facing COVID-19, this calculus is reversed, as the populations most afflicted by COVID-19 are those in the most disadvantaged groups. To give them some offsetting privilege from their possible immunity would therefore be likely to reduce rather than increase the inequality of well-being. Hence to enable and encourage those with immunity to get back to work to help those still at risk is not only good for them, but likely to reduce inequality of well-being in the process.

References 

Helliwell, J. F., Huang, H., Wang, S., & Norton, M. (2020) Social Environments for World Happiness. World Happiness Report 2020. Chapter 2.

Olivarius, K. (2019). Immunity, Capital, and Power in Antebellum New Orleans. The American Historical Review, 124(2), 425-455.

Sachs, J. (2020) The East-West Divide in COVID-19 Control. Project Syndicate, April 8.

Stock, J. H. (2020). Coronavirus Data Gaps and the Policy Response to the Novel Coronavirus.