With COVID-19, when you have seven confirmed cases, responding as if you have 7 cases is responding a few weeks too late. I would propose an approach that models a projected scenario three weeks later, asks what measures we would take then, then proceeds to have those measures implemented today. Here is the reason.

On 28th January, Italy had only two confirmed cases. For the next three weeks up t o 18th February, they had only one additional case bringing the total to three. Then suddenly, there was an explosion of cases and a wild-fire like escalation. It seems like out of the blue, COVID-19 went out of control. Why did this occur? The truth is that it was never out of the blue. Understanding how the Sars-Cov-2/COVID-19 spreads and presents suggests that this pattern was always possible. Data from countries that have witnessed exponential spread suggests that confirmed cases especially early on are a true tip of the iceberg. They represent a small view of a bigger problem festering underneath the surface: spread among yet unknown and unsuspecting individuals.

Confirmation of the first cases requires a series of things:

  1. A symptomatic patient meeting the case definition who either presents to a facility or is identified through a robust screening process
  2. The presence of mind by the healthcare workers to link this patient to COVID-19 and act as per protocol
  3. An accessible and reliable diagnostic laboratory

These seem reasonable until we realize that:

  1. COVID-19 can be symptom-free for up to fourteen days (one case is suspected to have been symptom free for much longer).
  2. There is an indication that the virus can be spread for up to two days before the onset of symptoms.
  3. 80% of patients will develop only mild symptoms that are indistinguishable from common ailments, and may never present to hospital, especially early on.

All these mean that the likelihood that all or even most of actual initial cases will present to a hospital let alone get tested for COVID-19 is very low. They continue to spread the virus nonetheless and it is this unknown population that bears the greatest risk to our health system with a large number of possible new infections among people who do not even know that they are sick. The magnitude of the problem would become evident only two to three weeks later when symptoms start to show and a big enough population has been infected. Countries like South Korea, Iran, Italy and many others have gone through this very cycle. If we are to learn any lessons from them, then we should take every measure to ensure that we limit this invisible spread, appreciating that it is likely there. If we wait for the numbers to hit a hundred, we might very well be too late.

For instance, having churches and schools closed and bars and clubs opened is not a situation we should be happy about.

It is understandable the concern of those who advocate for conservative, less drastic measures: the economic disruption should we take drastic steps. Perhaps we can learn from the same debate when we were considering limiting flights: concern about the impact on airlines and economic ties made us delay shutting down borders. Fast forward a few weeks later and the same drastic measures we were trying to avoid are now in place, only that they are no longer enough to contain the situation and more drastic, and economically costly measures will be required. The same is likely to happen with other drastic measures being considered today. If we delay them, it is likely that we will still be forced to implement them but in situations in which they will no longer be enough or as effective as if they were to be implemented today.

If we have reason to believe that COVID-19 will fade away, then the conservative measures will do. If however we see a scenario in which the infection will spread, and that is the lesson from other countries, we have to try get ahead of it. That means that we implement today the measures we are contemplating putting in place three weeks from now. That means reacting not to the numbers we have confirmed today, but to what we see those numbers look like three weeks from now. This way, we give ourselves a good chance to succeed.

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