Managing CoVid-19 pandemic without flattening the economy and the poor - this template can still be adapted by individual countries to mitigate costs!

Is there a better way to manage the corona pandemic until we develop a "herd immunity" or find a cure or a vaccine - than cyclic lockdowns and "controlled releases" with social distancing norms ( > 1 meter as per WHO guidelines)? [Now it is known that CoVid-19 herd immunity is not likely to be achieved even in those regions where there was no lockdown or there was a lax lockdown; vaccine will not be universally available before second quarter of 2021 - see references updated in  the worksheet link at the bottom - 19-Jul-20].

Experience shows that flattening the curve and delaying the peak of acute infections requiring hospitalisation cannot be accomplished by any country in a single wave as shown here. With few exceptions (e.g. Sweden and Brazil), no Country's leader has ventured to completely relax or remove even tough lockdowns quickly. The reality of the curve resembles a sine wave (rather a shape of saw teeth wave) - or at least this is what is expected in most countries because of the prevalent (default) "policies".

The current policies of cyclic lockdowns and relaxations with social distancing mandate will result in following outcome of waves of ICU cases or infections (with higher numbers) until a cure or vaccine is found and administered to all.  

Wherever, the peaks overshoot the healthcare capacities, there will be high CoVid-19 Case Fatality Rates - like it happened in Lombardy - regional CFRs will be much higher than national averages.

At the outset, this blog is not analysing the past actions, rather what we may do going forward. The new strategy involves taking actions in parallel, until transition (what is referred to below as "transition stage") is completed.

I think certainly there is a better way than the bouts of lockdowns followed by relaxations. Most scientists, economists and engineers are likely to agree with this better way but most top politicians, who dominate policy making, have unfortunately no clue. What is worse is that World Leaders, with few exceptions (e.g. Angela Merkel - she is vocal and has the heft and qualifications; Xi Jinping too has the heft and qualifications but he is not vocal as he finds himself on the back foot due to the mystery  of the circumstances of patient # 0 in Wuhan) have not talked about cooperating or funding joint programs to combat the pandemic. Without a huge collaborative program, driven by a global consensus, we will pay a huge price. Cost of failure or under performance is in trillions of dollars and millions of lives or compromised livelihoods. Yet the politicians don't seem to care.

The proposed program outsizes any previous collaborative human endeavour by two magnitudes (compared to OS/360 or Linux or Moon Shot or ongoing ITER project)..  

My prescription has elements which have been discussed before and some have even been implemented, notably in China, South Korea, Taiwan, Singapore, Vietnam and Taiwan. In this note, I am just laying out the contours of a composite strategy that wraps around these elements - from the vantage point of a Information Technology Consultant and few animated discussions with epidemiologists, a public health institute director and articles I have read or news I have watched (references are mostly at the end). It should be easy for the reader to figure out the difference the prescribed path may make. It is expected the majority of people are likely to experience the monetary and non-monetary costs of the current regime pretty soon and there may be agitations and even law and order incidents in its opposition - as happiness of hundreds of millions will be finished.  

The current regime may be referred as one of "societal level lockdown and social distancing mandate". What we should be implementing is a regime of "individual level lockdown (= quarantine) without a social distancing mandate"!

First, lets get our arms around the costs we will likely incur going down the path of "societal level lockdown and social distancing mandate" that almost all countries are following -

Economic cost: North of 8.5 Trillion USD (Source: UN Report) / 9 Trillion USD (Source: Gita Gopinath, Chief Economist IMF) - this works out to a loss of 10% of Global GDP or about 1100 USD per head

Human misery cost: About half-billion additional people will be pushed down the poverty line (income of < 1.9 International Dollars per day; UN definition - an international dollar equals 1 US Dollar of 2011 inflation neutralised); millions may die due to starvation or malnutrition

Human performance & psyche damage: constant wearing of face mask after stepping out of home, trying to maintain 1 meter physical distance, constantly washing hands with soap and sanitising surfaces touched by others will drive people bonkers; the pressure of running enterprises, buses, trains, planes, ships, hotels, restaurants with less than 50% attendance or load factors will cause business owners to develop high BP or go into bankruptcies. Running schools with kids who don't understand social distancing will be nonviable. Collaboration cannot always be done via Internet.   

Second, lets understand why "social distancing" + wearing a face mask is being mandated today? 

It is because, one doesn't know the status of an individual one is going near is an (active) infected person who is shedding virus - and risk picking up the infection. When one doesn't know own status too, one should not go within 1 meter radius of other individuals and risk infecting them. If every individual's "infection" status is known with a reasonable level of accuracy, and it is possible to automatically read the status by a smart AI based program (lets call it CCA - Cloud based CoVid Adviser), then this mandate of social distancing can be dispensed with. 

Third, lets understand why washing of hand or sanitising surfaces is being recommended today?

This is because one may touch surfaces which have already been touched by (active) infected persons and the virus remains potent for few hours to few days! If we have a system that infected persons cannot reach those places where one is visiting or working or studying or playing then the virus will not be sitting on any surface in those places so one can forget about frequent washing and sanitising. 

It is unthinkable how the above ideas can be sold as the "new normal" for the next 12 months (no guarantee that this period wouldn't be much longer)! I have not mentioned issues due to density of populations in areas like Dharavi and millions of homes across the world which are separated by a thin wall, if at all! There are millions of people who do not access Internet; anyway everyone cannot work from home.

PRESCRIPTION, GOING FORWARD:

First, the required Technology components - 

every individual will be required to wear a band or a tag - each country's government will decide if it wants to fund the total cost or citizens will be asked to pick up part of the tab.

The wearable band capability: the Active RFID + GPS tracking + BLE (Blue Tooth Low Energy beacon) will broadcast the individual's ID and GPS coordinates; Active RFID+GPS can be read via satellite if a pocket device is carried or else if the subject is in a microwave cellular zone, BLE beacon can be read by another smartphone within 80 meters. Optional add-on features of the band: temperature, pulse rate and blood oxygen saturation level measurements and broadcast.

Every country will have a national database and its CCA will generate dynamic alerts and QR codes with validity date in four colours for each individual:

Green - not infected - free to move about and intermingle with other "greens" until the validity date

Yellow - susceptible - should not move about and should head to a test lab for the recommended test  before the validity date

Red - active infected (currently shedding virus) - may or may not be symptomatic - should be quarantined at home or in an administered facility or isolated in a hospital depending upon the symptoms

Blue - infected (past) and recovered with antigens detected - free to move about upto the validity date

AI program will dynamically determine the validity date depending upon the profile of the individual and his/her profession - for e.g. healthcare worker will have to undergo DAILY tests - so his/her green code will change to yellow code past 24 hours unless the individual gets retested and the results are updated by an authorised person 

The objective of the action plan is to live life as in the pre-Covid-19 era, perhaps with greater sensitivity for fellow human beings and environment, and return the world economy to the pre-Covid-19 state through universal testing in which individual level quarantine will be recommended rather than societal or community level lockdown.

The action plan has three stages: 1) R&D stage (through WHO)  2) Transition stage (National) and 3) Saturation stage (National) 

1. R&D stage (1 month) - will be supported by the UN member States contributing to WHO @ 0.1% of respective GDP (so we are talking about 87 Billion USD allocation to WHO - India's contribution will be Rs.20K crores - compare with Rs. 20K crores for redevelopment of Rajpath Central Vista - new Lok Sabha project fast tracked recently) The IP will belong to UN and each member will get the product (x numbers) and know-how without additional cost
   - to develop smart tests - both types -
   
   
   (a) rRT-PCR also called molecular or genome or nucleic acid tests - presently this could cost, at scale, USD 5 and takes 5 hours - target should be to drop the cost and time to one fifth - and also produce a home kit. (Updated 26-Nov-20 Now a days Rapid Antigen Test has become popular - it produces results within ten minutes; nasopharyngeal swab is taken and test is conducted in the field by junior medico personnel - RAT's specificity - false negatives - is much lower than RT-PCR test, therefore, those with symptoms but tested negative are advised to go for RT-PCR test which has close to 100% specificity - it will hardly produce any false negative results; RAT tests are being offered for free by Government and RT-PCR tests @ Rs.1500 by private Labs) 
   
   
   (b) Serological (blood) tests - presently costs 5 Cents and takes 15 minutes - target should be to provide a home kit and drop the cost and time
   - the former tests detect presence of SARS COV-2 virus and the latter detect presence of antibodies which the body develops after recovery from CoVid-19 has started or is complete. 
   
   
   (c) Wearable band - with active RFID + GPS tracker and BLE beacon - the design will come from WHO, however, even without WHO, India could develop it with a R&D budget of about Rs. 100 crores. Its acquisition cost to the government can certainly be kept below Rs.1K per piece which includes its distribution cost in the Transition stage. The individual's ID will be his/her Aadhaar in India - other Countries can choose their own ID
   
   
   (d) CCA development - this program will have three components - satellite deployment using Cloud Data Centres; Android and iOS Apps; international protocols (API for exchanging data of individuals who cross national borders) - source code will be given to each member State and they could modify it if needed
   
   
   WHO will outsource the R&D and initial lot's production to private or public sector companies worldwide. Funds left-over from the R&D budget will be utilised to actually produce testing machines or kits for distribution to member States. 
   
   
   During this first stage, Legislative support will need to be put in place in every country - the proposed surveillance system must be temporary and data access must be limited for the specific purpose to contain pandemic and nothing else. International protocols will have to be agreed to which will enable communication between the programs of each country - when an individual moves across a border, his/her data will be exchanged. Objections of violation of data privacy are a piffle when compared to the costs described above (of course countries like China will just pass a diktat and get it over with; even India has implemented Arogya Setu without any legislative support - this is a risk the Government has taken because it is not taking legal challenges seriously due to a friendly Supreme Court).
   
   
2. Transition stage (1 to 6 months) - A national level CoVid database of all individuals will be created by pulling IDs into the individual's record seeded with Aadhaar in India and entry of profile data while on-boarding - which will be outsourced to agents - like it was done in the Aadhaar project.
   
   

2.1 Test machines and kits will be productionised and distributed (or sold) to labs and home users - especially to the susceptible people

2.2 Wearable band will be productionised and distributed to every Indian resident - who will be mandated to wear it

2.3 Initially CCA will assign Yellow QR code with a validity date - this means every person will have to get himself/herself tested (CCA will advise which test - RT-PCR test or blood test - to get done) and get results uploaded by an authorised lab person - the program will alert each user with action to be taken - including useful information like the nearest couple of testing labs; CCA could include database of authorised Labs and it could easily provide online test scheduling functions - booking appointments and preventing crowding at Labs

2.4 Individuals who test positive on blood test for antibodies or negative on RT-PCR test for CoVid-19 infection will be given Green QR code with a validity that will be algorithmic ally assigned - profile of user and place of residence will influence determination of the validity date as already mentioned (CCA may advise to get only one test or both tests done - one after the other depending upon the results - for e.g. Negative result in Blood test may be followed by RT-PCR test or a positive result Blood test may be repeated - AI program will use the updated knowledge base and learning about the reliability of tests and the durability of immunity; a person who tests positive on blood test establishes that s/he was infected earlier and is recovering or has recovered - in which case this person would be assigned a blue status after a certain number of days during which a yellow code may be assigned with a message that you need to self-quarantine and at the end of it you will get a blue code, with or without any further blood test).

2.5 Individuals who are found in places (GPS + BLE beacon can be read to determine x,y and z coordinates - ambiguity in multi-storied buildings may be resolved by access control measures - automated or manual) where they ought not to be, will be warned - police may be alerted for suitable action (for e.g. a red code person cannot be in any place other than home or hospital) - people who have mobiles will receive alerts - others will be reached through their designated friend or relative whose mobile number will be input in the profile. 

2.6 Whenever test results are uploaded from an authorised person, the individual's colour code may change and QR code regenerated. Users will be advised to wear a physical tag with the colour QR code and their photo printed - this printout will be generated through CCA only. Upon being challenged, the band worn by the individual may be read by the CCA program running in the smartphone of the challenger (police officer or a security officer) and the user's biometric (fingerprint or iris scan or facial image) used for authentication against the central ID database (UIDAI in India) - biometric wont be stored in the CoVid database. 

If India can manage to on-board 10 million persons daily, then it will take 130 days, if we can double the rate, it will take 65 days to on-board the whole population. The system will pay off with even 70% population on-boarded. Ro (R naught) will drop < 1 and the epidemic will die down (Ro was 1.23 between April 13 and May 10 in India - read here).

Costs of tests: Assuming the current costs of genome tests (equivalent to RT-PCR tests) @5 $ and Serological tests @ 5 cents (average cost in a large deployment drops drastically - these rates were achieved in 2018 in Egypt and a weighted average frequency of 6 tests of each type per person p.a., the required budget for India = 5.05 x 6 x 75= Rs.2,272 per head p.a. or Rs. 2.95 lac crores p.a. (~ 1.5% of GDP)

3. Saturation stage - after everyone is on-boarded, why will the infection spread or remain and why do we need to continue running CCA?
   
   
   It is because no test is perfect. RT-PCR tests and Serological tests produce false positives > 0 (sensitivity is < 100%) and false negatives > 0 (specificity is < 100%). Therefore, the surveillance program will have to be continued to be run until herd immunity is developed (almost everyone has blue QR code) or a cure or vaccine is found and administered to everyone. 

CONCLUSION: 

With the cooperation of all member States, the proposed program should be launched through WHO so that best solutions can be quickly developed, shared and operationalised - and individual's data shared through common protocols to sustain unrestricted international travel and allow people to go about their business without physical distancing and wearing face masks!  We can weaponise any or all these against CoVid-19: 1) Test + Apps, 2) Cure and 3) Vaccines. Since the no. 2 and 3 may take over 12 to 18 months, or longer, to weaponise, we must spend 2% of Global GDP on weaponising no.1 remedy otherwise we are heading for a disaster.

The current regime of cyclic societal level lockdown and conditional relaxation with the vogue of "new normal" has huge avoidable costs. Both the economic cost of over 10% of GDP and human impairment cost can be drastically mitigated by the regime of  "individual level lockdown (= quarantine) without a social distancing mandate!" We need to change our discourse from false choices so that lives AND livelihood both can be saved: we must collaborate and go for "Test + Wearable Band + Apps".

References: worksheet with links

Corona testing budgets.xlsx