Here's the COVID Exit Door -- Will We Walk Through It?

John Whyte, MD, MPH; Yaneer Bar-Yam, PhD

Disclosures

February 18, 2021

Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

  • We've had a "live with the virus" strategy, but instead we need a "no COVID-19" exit strategy that drastically suppresses the virus.

  • If states, or the entire country, committed to a 5-week strict lockdown, it could create virus-free "green zones." Then, temporary travel restrictions could protect these virus-free areas.

  • Previous lockdowns were not strict enough to eliminate the virus.

  • Schools are dangerous spots for virus transmission. A 5-week lockdown that includes schools would make it safer to reopen them after the lockdown.

  • COVID-19 cases could increase dramatically because of the variants. Vaccines are not going to solve the problem in the short term.

This transcript has been edited for clarity.

John Whyte, MD, MPH: Welcome, everyone. You're watching Coronavirus in Context. I'm Dr John Whyte, chief medical officer at WebMD. Everyone is talking about the variants and how we need to vaccinate as many people as we can. Some experts are suggesting that that's not enough; we actually need a no-COVID strategy, an elimination strategy.

To help explain what that means, I've asked Dr Yaneer Bar-Yam to come back. He is professor and president of the New England Complex Systems Institute. Dr Bar-Yam, welcome back.

Yaneer Bar-Yam, PhD: Thank you.

Whyte: So, what is this elimination strategy? Aren't we actually trying to do that?

Bar-Yam: What we've been doing is the "live-with-a-virus" strategy, which is not working very well. What we end up doing is giving up our ability to do what we want to do, and we have the virus around that is causing all the disease, disability, and long-term consequences. The problem is that there is not an end to this that we see, even with the vaccination. First of all, it's clear that we can't get out of this with 6-12 months of vaccinations.

Whyte: Why is that? Why do you say that? Take, for argument's sake, that we can reach 70%-80% immunity. Many say we're not going to reach that, but let's be optimistic and say we will.

Bar-Yam: First of all, that will take time. You can estimate that it will be about 6-12 months before we have enough vaccines to get to the level that would protect the population. We've already seen that some variants are reducing the effectiveness and will undermine the vaccines. Then, we are talking about having another round of vaccinations, boosters, or multivalent vaccines. All of that means we don't know that there is an end to it. We see that with the flu, where we need vaccines every year, and they still don't protect us.

The current situation is not an end game; it's just a way of perpetuating the harm that the virus is doing, both to our health and the economy. So, what is the way out of this? We need an exit strategy — one of these exit signs on top of a door that says, "This is the way out." The answer is that we already know what that looks like.

We have to drastically suppress the virus, and we have to realize that where we don't have virus, we can open up normally. We can open up normally by protecting areas using restrictions of nonessential travel for a short amount of time — not a long amount of time — until other areas are able to open up also without the virus.

Whyte: You stated that we have to use nonpharmacologic interventions and lockdowns as well. We've talked about that before. Is it these targeted lockdowns, the creation of "green zones"? I want to ask you about that because some will say, "Can we actually get that done here in the United States?" There's so much resistance to that. And didn't we try that? Or we just didn't try it well enough? It's easy to say, "Let's suppress the virus." We all agree to that. But how do we realistically do that, recognizing what the sentiment is right now?

Bar-Yam: The main thing is to realize that it's not the same to get to a few hundred cases and say, "Hey, we're safe enough; let's open up." You have to realize that you need to get to zero. In the summer, there were many parts of the country that could have opened up safely if we had protected them and we had kept going in the other areas for a few more weeks.

Really, the question is not doing something completely different but doing it intentionally. It goes back to this issue of a fire: We have a no-fire policy. Our no-fire policy means we don't let fires burn in houses; we don't let fires burn in the city and then put them down when they're big enough. We put them out [right away].

Whyte: We talked about the fire metaphor before, and it's a very good one. We don't just do certain sections; we try to get it out completely. So, let's be very practical. Tomorrow you're in charge. What do you do?

Bar-Yam: The question is, what am I in charge of? We could do this in a town, a city, a country, or a state. It's super straightforward. We say, "Look, we've been living with a virus. We do not want to live with the virus." All the ideas of finding some way to live with it are not working. So, we're going to make this decision to get rid of it. In order to get rid of it, we have to do the strong action over just 5 weeks. We're going to do all of the things we know: a stay-at-home order, drive-by pickup, or delivery. We're going to protect family members by making sure that if someone is sick, we quickly isolate so that we don't infect others. We're going to do all of that. And then in 5 weeks, there are going to be many parts of the country that are going to be virus-free.

Whyte: How did you decide 5 weeks, scientifically?

Bar-Yam: Five weeks has to do with the incubation period. It's 2 weeks for the first incubation period. We identify people who are sick, but they've already infected some of their housemates. We need another 2 weeks to eliminate those cases from being infectious, and then we need a little bit more.

This has been shown in multiple countries. If we really go all out, we can go down very rapidly. We didn't do all of that the first time, so it took longer. We lost patients. Then we opened up because we thought it was okay to open with a few cases. Why does a few cases matter? Because then it blows up again, as we saw.

Whyte: Did we have too many exceptions when people tried to say we were in a lockdown mode?

Bar-Yam: Absolutely. The point is, if you're trying to make it a little less bad, then you say, "Well, I'll do a little bit of this or I'll do a little bit of that." But if you say, "Look, we want to eliminate the virus. In my town, my neighborhood, I want to have the ability to meet with my family and friends, go to restaurants, and have everything open." The way we get there is by making sure that we don't transmit at all. Now, of course, some cases are going to happen; we can't avoid everything. The more we limit ourselves during the first time, the less time it takes, and that's the most important thing.

Whyte: You support travel restrictions, correct? So, you create these "green zones" and then you'd have a lot of restrictions on travel. Is that realistic when we have these very porous borders?

Bar-Yam: Yes, it is realistic. Again, the important thing to know is that it's not for a long amount of time. We're going to be really hunkered down for 5 weeks. It's a great time to do it, in the winter when there's a great cold spell, because we're not going to go out very much anyway. It's a good time to take all of the precautions.

Whyte: You would close all the schools.

Bar-Yam: Absolutely. Schools are very dangerous for transmission.

Whyte: Well, people have pushed back on that. Not everyone agrees with that sense of transmission in the schools. Is that correct?

Bar-Yam: There are two ways to say this; not everyone agrees with it. People are concerned about kids, taking care of them, and about not being able to work when their kids are home. All of these are issues. By the way, there is new information about kids with long COVID, which is very disturbing.

Whyte: But the Centers for Disease Control and Prevention says we can reopen the schools. Isn't that in conflict?

Bar-Yam: It is. Again, the whole point is that if we do it for a short period of time — you don't want the kids to be home for years and years — then not only can the kids go back to school, but they can go back safely, and everything can be done in the way we want to do it, which is without fear, disease, and restrictions that we need to follow if we are with the virus.

Whyte: In many areas, kids have been home for a year. You're suggesting that we haven't done it correctly in terms of the lockdown; it's been too liberal in terms of people being able to leave. So, we'd have this lockdown, which would be much more comprehensive than we've done before, but for 5 weeks. But then there's also a significant role of testing. And in some ways, we've seen testing decrease lately, where one can argue that we should be doing more testing, especially epidemiologic surveillance testing. Tell us about the role of testing.

Bar-Yam: The role of testing is to find out where the disease is, not just one person. One person is super-important, but everybody should be isolating as soon as they have any symptoms so that they don't transmit. Then they're tested. They know to isolate for the right amount of time, and we have to support them. One of the important things to realize is that in order for people to be able to isolate, we have to help them because many who are infected are workers that have to support themselves from week to week. So, we have to make sure that people are supported in being able to isolate themselves, as well as quarantine people who are their close contacts.

By doing that, we enable people to take these actions. Once they can take these actions, it's really not that long. We've been doing this for a year. Do we want to do this for another year or 2 years? If we don't control the virus, the "living with this virus," which is what we've been doing for the past year — we do not want to be living with this virus.

There is one exit. And this exit has now been declared by the editor-in-chief of The Lancet. It's been very clearly articulated by key epidemiologists. They say it's not only the thing that we want, but that it's possible. The main thing that we need to do is to recognize that we must do things that we wouldn't normally do, and that's okay because it's the exit. We just need to know to walk through the door.

Whyte: Is part of this a political solution as well as a scientific solution, meaning that we need to have that political leadership, that political will to make this no-COVID strategy happen?

Bar-Yam: The disease is biological, but the action that we need to take is a political, social action. It is about our desire to do something for ourselves and not to be at the mercy of this disease. And just to be clear, it's been super-bad over the past year, but with the variants it's going to get a lot worse. With a more rapidly spreading variant, it's going to go way back up very quickly, and we're going to have to take much stronger action and restrictions in order to just maintain it at a level that's not swamping our hospital systems and killing huge numbers of people who cannot even get treatment.

So, if we're not doing the right thing now, we will have to do much more restriction. Why shouldn't we get the benefit of getting to zero and opening up normally, which has been demonstrated to be effective?

Whyte: Where have we seen that happen?

Bar-Yam: We've seen it in Western countries, Australia and New Zealand. They have large cities and lots of traffic between them. They've done travel restrictions even within the city of Melbourne. They've put in travel restrictions in order to protect the areas that didn't have the disease so that they didn't have to lock down from the area that did have to lock down. We've seen it in New Zealand, which had an early, fast lockdown. We've seen it in Taiwan. We've seen it in Vietnam, which has a very high-density population with 100 million people. Even India is successful, where they have high-density slums that have been able to overcome the disease.

They've been able to do this by careful action, making sure that they identify cases, isolate people, and do testing where it's essential to figure out what's going on and to stop the disease. It was also done in China. So, we have lots of different countries, big and small countries, island countries, and Vietnam is surely not an island country. There are lots of different countries with different governments. By the way, it's also been done in Atlantic Canada, where they have a zero-COVID strategy. They have been taking care of the disease, have very few cases, and have been very successful.

Whyte: Those were done pre-vaccination, so there really wasn't a vaccination strategy. This really was a nonpharmacologic intervention.

Bar-Yam: The vaccination strategy has not been important anywhere in the world except for perhaps in Israel. And even in Israel, the outbreak now is at maximum. They're trying to have a solid lockdown in order to prevent the transmission. The vaccine is not going to solve the problem in the short term.

Whyte: Tell me how confident you are that we'll be able to institute this elimination strategy in the United States.

Bar-Yam: I've seen it being done in many places. Despite all of the people who say we're fragmented and so on, I know the US has a tremendous ability to rise to the challenge. If we're willing to give our all to winning, then there is 100% certainty that we'll be able to overcome this. It is not a challenge that we cannot meet.

Whyte: Dr Bar-Yam, I want to thank you for providing your insights for helping us to understand how an elimination strategy can work.

Bar-Yam: Thank you.

Whyte: And thank you for watching. If you have questions about COVID, drop us a line. You can email me at drjohn@webmd.net, as well as post it on Facebook, Twitter, and Instagram. Stay safe.

Follow Medscape on Facebook, Twitter, Instagram, and YouTube

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....