Countries have chosen to follow different strategies, and each will have a different impact.

Bradley Tanner, MD, ME, MBA
April 6, 2020

A country-by-country analysis is an effective strategy to try and predict the extent of the impact of the COVID-19 epidemic. Countries have chosen to follow different strategies, and each will have a different impact.

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The first one is obviously China which chose to let the virus spread early (by ignoring calls to investigate) and then to implement drastic police state powers. Those powers limited movement and activity of individuals, including enormous numbers of individuals such as the 60 million original as well as individuals throughout the country.

They have, of course, succeeded in stopping the creation of new infections through these measures as well as using techniques of rapid testing to identify people and control them on an individual level. Alternative conspiracy theories that somehow there were far far more deaths is unlikely. Hiding mass deaths is not easy.

The Chinese model, let's call it the Police State Virus Elimination Model, is fundamentally inconsistent with democracy or a constitution. It does not limit the power of the central government. Instead, it assumes it can control all states, all individuals, all movement, and pretty much all behavior of its subjects. For some, this may be a welcome cost-benefit analysis however, for most of us who have grown up in a country supporting freedom and democracy, this is an unacceptable trade-off, and we will search for a different model.

This is an important starting point since many discussions identify the "success" of China. Indeed, there are lessons, and some social isolation is useful. But the argument that we can or should follow the China Police State Virus Elimination Model is equivalent to arguing that we should discard personal freedom and the constitution. Since all our leaders and our military swears an oath to uphold the constitution, this is an unfathomable change. The second reason to discard a solution replacing the world we know with a 1984-equivalent police state is I think the strategy will fail in the end. More on that later.

The second state to look at would be Italy, which similarly initially let it spread but more quickly shut down several specific areas of the country. Though the initial efforts were nowhere near what China did. It subsequently found that it had to impose even more dramatic shutdowns and limitations on its population - in many cases resembling China, though still not up to the draconian levels of China, nor throughout the country.

As with China, it looks like it has succeeded in stopping the spread of infection; however, the overall death rate is significantly higher. In both cases, one must assume that if the spread completely stops, then there are a significant number of individuals that are still at risk of infection. In China, this is potentially successful in that it has the police powers to control individuals as well as the ability currently to stem immigration and ensure that new cases do not come. Or, if they come, they are tested and forced into isolation that is tracked by big brother. In Italy, it is unclear that this will be a successful strategy since, as we've seen from migrants from Syria, there's certainly an inability to control one's border as effectively as China can. In sum, the Italy model is not the China model. It was the beginning of the Herd Immunity Model. In the coming weeks, we will see what happens in the south of Italy as the virus spreads. One hope is the virus is already there, and herd immunity occurred in the south of Italy without all the draconian measures.

Is it mitigation? The press and our leaders use the term mitigation as if there were a mitigation model. This is confusing since some also recommend "ongoing mitigation" sounds like containment and waiting around for a vaccine. Mitigation is not herd immunity. It is hope. A hope we can slow a virus that is exceptionally transmissible through light police state, "stay at home for months" measures. We have to choose. There is no middle ground. Mitigation means holding back a virus that roars back as soon as we release it. If we fail, then we get herd immunity anyway. If we succeed, we delay the fight for another day and never escape the inevitable. The folks who propose this don't expand their models to ever release the limited police state. As soon as they do, the virus will spread. And if you think shutting down businesses/churches and being told that you cannot leave your home isn't a police state, you haven't been reading much science fiction or watched the Empire Strikes Back. Those are not requests; they are backed up by fines and, in some countries, jail time.

The next state to look at would be Spain, which waited somewhat longer than Italy and had a more countrywide spread of the virus and then subsequently implemented a lockdown that does not appear to have ever been as Draconian as Italy yet still quite severe. It also has fewer hospital resources, and that too may have affected the spread. It had an even higher rise of disease incidence; however, it also is plateauing. Interestingly enough, the overall death rate for the population is approaching the same rate that is seen in Italy. We may be seeing that there is a death rate per population that is potentially independent of the distancing interventions that one implements. The only explanation for this would be that they are both following the Herd Immunity Model and that social distancing may be helpful but to a minimal extent.

To clarify, the difference then between Italy, Spain, and China would be China is living in a world that has no herd immunity and has high susceptibility. And potentially there is some herd immunity developing in Spain and Italy which is assisting it.

The next most apparent hotspot is New York City - not the United States. I highlight NYC since it represented 75% of the "New York" cases early on, and most of the US cases. So it was not a "New York" problem actually. Those numbers decreased as it spread to Long Island, but it remains almost primarily an NYC phenomenon.

New York City is a unique environment compared to all others in the initial creation of the epidemic in that it is highly congested and has enormous amounts of immigration. It also is a hospital Mecca and has expanded its healthcare system far beyond the capabilities of every other potential hotspot. With all those in mind, New York has clearly shown the worst rates and the most rapid rise.

The lessons from New York would be that some environments of congestion and slow response will still lead to enormous rises in the infection rate, which are virtually unstoppable. The most apparent blame is the congestion of NYC. But the pictures show people in buildings who are not leaving vs. images in other parts of America. I doubt blaming insufficient distancing (though convenient and supporting the police state model) is the explanation. More likely, it shows the weakness of the distancing model and highlights that even after one implements distance measures, it spreads rapidly. Why?

We are starting to see the HealthCare Overinvolvement, Hype, and Panic Model. In this model, one instills a constant media barrage of public networks and public officials that keep telling everyone to be calm while at the same time providing no useful instruction and tons of repeated stories highlighting misery. There is a ton of blame and finger-wagging. People run to get tested and run to hospitals in response to the fear-mongering and lack of advice. The care system spreads the virus widely and at high doses. It confines the sick to makeshift hospitals that further the spread and severity of the illness. The endless cycle continues as hospitals, and hospital-based care systems continue to spread the virus at a rapid rate and until herd immunity is reached. Then life returns to the more measured Herd Immunity Model. And that is what is happening. Higher misery, more deaths, but they achieve the same result.

Why is the percent of deaths per population higher in NYC if they eventually reach herd immunity? Why is the rate significantly higher. Is the virus somehow more lethal in NYC?

Deaths are caused by preexisting conditions primarily and age. Those factors are not all that different. Italy is older but had a far lower obesity rate. The other factor is the viral load. Any my postulate is all the fear-mongering, and underutilization led to higher exposure initially and subsequent severe infection and poor personal response.

Some will say the healthcare system was overwhelmed. Perhaps. But perhaps the system was overwhelmed due to hype and poor instruction. New Yorkers did not get the message to stay home, rest, and not get tested like they are in the UK. We heard about testing, testing, testing far after testing was providing any value since "case-detection and isolation [a feature of the China Model] were indeed no longer relevant given the widespread nature of the infection. It's an unpleasant conclusion, but the HealthCare Overinvolvement, Hype, and Panic Model lead to higher deaths despite reaching the same outcome.

Additionally, we cannot ignore the other lesson that is potentially being learned in newer (state of the art) healthcare systems. That trade-offs may need to be made and that we can no longer afford to throw all resources in the hope of saving all lives. The NYC hospitals have not published their data but with reports of 20-30 days on a ventilator. Given a high rate of death seen in Seattle once ventilation starts [Bhatraju PK, Ghassemieh BJ, Nichols M, et al. Covid-19 in Critically Ill Patients in the Seattle Region - Case Series. N Engl J Med. March 30, 2020. doi:10.1056/NEJMoa2004500. PMID: 32227758.] it may be that the overwhelmed nature of NYC was an inability to accept the reality that in a pandemic, difficult decisions need to be made. Clear and focused decision making also can potentially decrease the spread of the virus and allows us to allocate resources more efficiently to patients with the greatest chance of success. We await data to see if overutilization paradoxically caused more deaths.

By comparison, the rest of the United States is significantly less infected and is suffering from significantly fewer deaths at a percentage level. We've been warned that the misery and death toll of NYC will come to the rest of the US. More on that later.

Outside of New Jersey and Long Island (also congested and full of hospitals and subject to the same media blitz and FUD), we haven't seen that. We know that people left New York to escape the fear, panic, and lockdown and traveled far and wide. It's doubtful they all stopped 100 miles away in New Jersey and Long Island. So there is something unique about this hotspot in its severity.

The lesson is clear. Turn off hype, turn down the volume, stop daily briefings with no useful information. Start providing helpful information, keep people at home as long as possible, and stop testing the worried.

France and the UK are following behind NYC and more consistent with the non-New York City part of the United States. France chose a more leisurely model, which would have led to the early rapid spread. And the current rates would be consistent with a spread that is more similar to New York City and Spain. It's likely that it will follow the same trajectory as Spain and will potentially achieve a similar death rate as herd immunity is created. It does not appear to be enveloped by the same FUD (fear, uncertainty, doubt) that gripped NYC.

The UK followed an even more leisurely model with the unsurprising rapid growth of the virus. It will follow a model similar to France, and the numbers also show rapid spread and then a return to a lower baseline once some social distancing was added.

They both have a universal and coordinated health care system. They have provided clear advice, and despite public calls for testing, they have not pushed testing as broadly once the virus spread. Was it a mistake that they were "relaxed" for so long? Perhaps not. The relaxed state let the virus spread more widely. It could then spread at a slower rate once some distancing was put in place. Theoretically, that "delay" allows them get to herd immunity faster.

In sum, they are pursuing a Faster Herd Immunity Model and will see similar results, probably better results than Spain and Italy.

The rest of the United States is clearly on a different trajectory than the NYC metro area. Many claims are being made that the rest of the US is simply behind in terms of weeks. However, the data doesn't support an impending huge rise, as we have seen in New York.

Unlike New York, the rest of the United States has the benefit of less congestion, less immigration, and earlier interventions that distanced individuals. No doubt that is helpful, but there are congested areas of the US and areas that responded slowly. In fact, the rise in cases, hospitalizations, and deaths appears to be much slower. And the few hold out states in the rural US that emphasize distancing but allow a business to continue are not seeing worse outcomes. Most of the United States does not have the health resources of NYC, and potentially that is a factor, but congested areas have exceptional hospitals too.

What the rest of the country has is calmer or perhaps less compliance. The states in the rest of the US are continuing the rapid spread of the virus, the numbers are going up, but panic has not set in. Georgia opened the beach, and people went. In essence, the rest of the US is following an even more calm version of the Faster Herd Immunity Model. And I expect their number of deaths will be even lower. After initial rapid spread, the virus is spreading at a slower rate, which will eventually probably reach the same amount of herd immunity; however, that rate will enable the healthcare system to respond more accurately to the cases. Some (California) will claim that their distancing instruction deserves total credit. But outside NYC, we have not seen the same level of fear and panic and overuse of the care system in a downward spiral. And many areas (typically less congested) have not been as draconian in shutting down the economy and stopping people from work. They are doing ok too. Sure the virus is spreading and as it does, infecting some, and leading to some deaths. But at similar levels.

But isn't health care in the US fragmented? It was. But more recent areas of the country are dominated by a few vast systems with coordinated care (UNC/Duke in NC, UPMC in Pittsburgh). Those areas are providing coordinated care vs. the competitive and numerous systems in NYC or Boston.

The lesson may be that Herd Immunity is the goal, and the emphasis should be on reaching that state at a reasonable speed and with calm. Isolation of those clearly at high risk is essential. Complete isolation as in a police state simply delays the inevitable development of herd immunity and is impossible in a democracy.

Other developed countries that have little to few infections at this point can draw similar conclusions to the results and tactics of the UK, France, and the non-NYC USA. The population death rate is subject to change with additional data and alterations of the model to predict the global impact. Potentially other measures achieve even better outcomes. The key to finding them is to keep our minds open to the full range of explanations and possibilities and to question conventional wisdom in a situation where there is no existing precedent to guide us.

Although all countries are different, if our assumption is that the overall rate is based on widespread infection throughout the entire population, the rate seen in France, UK, and the non-NYC US should be a useful guide. We must still adjust for variations in average age and in the health status of individuals in different countries.

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