Disclaimer: I am not an epidemiologist, and my knowledge of the field is limited to what I have learned from the following experiences: 1) being a person who has lived through 2 years of a pandemic 2) having played a decent amount of Plague, Inc. (for whatever that's worth) 3) having taken a microbiology class when I was in college. So what I say should be taken in the sprit of proposing potential solutions, not as an assertion of what we know will work. This is babble, not prune.

So, we're in the middle of a pandemic. COVID-19 has been causing problems for 2 years, and the US (like many countries) is now seeing the largest number of daily cases that it's ever experienced (!). The question I want to explore is: What can we do to make this pandemic end? A related question asks how we can eradicate other viruses that are causing problems, including flu and the common cold.

Some might hope (as I've heard some suggest) that with Omicron swiftly sweeping through swathes of people, a very large fraction (90%+) will be infected with the virus, and some of those people will die, but the remainder will become immune, thereby leaving COVID-19 no more room to propagate. One might hope this ends the pandemic globally over a period no longer than 90 days.

Indeed, we should expect that this very dynamic will cause Omicron to spell out its own end, as well as the end of the Delta variant and the original variant that started this mess. But I would also remind you that there are many, many particles of Coronavirus around the world, and many of the particles carry a wide variety of mutations that are seen in neither Omicron, Delta, nor the original variant. In my estimation, it is almost inevitable that one of those variations will provide enough resistance to immunity to allow it to cause problems long after the Omicron wave is over- and I don't expect that that variation would be the last variant of Covid we face, either.

But who knows, it could be that I'm not right on that. If Omicron really does spell out the end of the Covid-19 pandemic, then consider the rest of this post to be a discussion of what we might do if another pandemic happens down the road (which I hear experts assign too high of a probability to for my comfort).

Our toolbox

We have various tools in our toolbox: Masks and other protective equipment; lockdowns; quarantines; border closures; But the most powerful tool in our toolbox are vaccines. With vaccines, a person can both cut down dramatically on the probability that they get infected by a virus, and reduce the severity of the disease they get if they do get infected (and a corollary to this, is that they are far less likely to infect other people when vaccinated). The Moderna vaccine (which is what is providing me with protection) was developed over the course of 2 days in January 2020, before the United States even entered its first lockdown, though it took several months for it to be approved for use in the USA (and basically everywhere else). I mention this to illustrate that not only are vaccines effective, being able to effectively shut down a virus if enough people receive them (though that part has proven to not be without issue), they can also be very rapidly developed and adjusted to respond when new versions of a virus emerge.

While we should be willing to use all tools in our toolbox, not just vaccines, to respond to changing situations, we should rely on vaccines as our main weapon against the pandemic, and deploy up-to-date vaccines as quickly as possible, when considerations of safety and public willingness allow for it. This is because vaccines are the only tool we have that can stop a virus in its tracks without causing undue damage to human productivity and human happiness (note that while vaccinated people can be infected, and can even infect others, when there's a low enough density of non-vaccinated people in a given population, the reproduction rate will fall enough to make the virus disappear instead of growing exponentially).

But when I say "when considerations of safety and public willingness allow for it", that should not be taken lightly, since we have so far been unable to navigate matters of safety and public willingness to a degree necessary to allow us to effectively use vaccines to defeat the virus. Some specific cases where we have so far faced issues:

1) Verifying and certifying that a vaccine is safe has taken orders of magnitude longer than actually developing the vaccine

2) Even once a vaccine is certified to be sufficiently safe, substantial numbers of people feel uncomfortable being vaccinated. This may be to lack of trust in the producers of the vaccine (which can be understandable), or due to their standards of safety being different from the standards of safety of society at large, or due to misinformation (which is unfortunate, and a signal that we need to improve society's ability to handle misinformation while respecting people's freedom of speech and thought, but it's hard to blame too heavily the victims of misinformation when it's so endemic).

This presents an interesting dilemma, where we both find it desirable for people to be able to live in an environment devoid of non-vaccinated people if they so desire, but where we also should be somewhat uncomfortable with forcing people to be vaccinated, because forcing things on people that are known to have impacts on health, and where people don't trust that the thing they are being given is what they're told it is, is a thing that we should generally be uncomfortable with. (To be clear, I'm not saying that we can't or shouldn't do this. Sometimes, especially in matters where people's life or death depends on other people's choices - like in war, and like in a pandemic - society needs to be able to make hard choices for other people. But I am saying we should be *uncomfortable* if we do find ourselves in a position of having to make that decision - and while I'm strongly pro-vaccine, I will also note that the lethality of Covid-19 is not so high that the case is cut-and-dry)

2a) People who want to be vaccinated, and who would prefer to not be around non-vaccinated people, live in the same cities and regions as non-vaccinated people who feel uncomfortable with being vaccinated.

3) Even once a vaccine has been approved, it is only approved according to a specific dose regiment - doses must be taken with specified intervals between them, and the dose received must be a specific amount - no more, and no less, than what is specified. This has proven particularly problematic, since the size of the dose specified was too large, which caused two problems: the short-term issue is that we were wasting vaccine when we were constrained by supply (both supply in the US, and globally), causing many people to be unvaccinated unnecessarily for months, and the issue that is still a problem is that the reactions people's body had to the vaccine were noticeable, decreasing people's willingness to get vaccinated, while a smaller dose would have provided similar protection without harming people's health.

To address these concerns, I propose the following:

Vaccine-only zones / cities

To address problem 2), there should be areas that are designated as vaccine-only, where people should only be allowed to enter or live in the area if they are vaccinated (this does mean that a perimeter would have to be set up around the zone, to prevent the entry of non-vaccinated people; people who are unable to be vaccinated for recognized legitimate health reasons would be exempted, as long as the density of exempted residents doesn't exceed a certain threshold). This would allow people, especially people who are vulnerable, to be able to live in an environment where everybody is vaccinated, while leaving people the freedom to decline the vaccine without burdening those who value herd immunity. Ideally, the zones should be established in sparsely-populated areas close to established cities, to prevent there being problems with having to relocate people currently living in the area who don't wish to be vaccinated - if the zone is sufficiently sparsely populated, an exemption can even be granted to the prior residents, without unduly harming people's protections.

The zone should become self-sufficient to allow people to live and work and do everyday things while staying surrounded by vaccinated people, but residents would be able to come and go as they see fit (if someone does get infected, herd immunity would prevent it from becoming a big problem in the community). Residents in these zones, by choosing to live there, would consent to follow the guidance of the zone leadership as to which vaccines are necessary (and safe) at any given point in time to address the shifting diversity of variants.

More lightweight regulation of medicine, particularly vaccines

The reason why the FDA exists is to make sure that people don't buy stuff they think is medicine which will help them, only to get hurt by what they take. This is a good cause, and it's important for people to be able to buy medicine without having to doubt if they've bought something that's actually going to be bad for them. But, it's also expensive and slow to move medicine through the FDA process, and this often kills people who have problems that can be solved with medicine that has been shown to work, but not up to the very high bar that the FDA sets (and we can't just say we'll lower the bar, because then people wouldn't be able to trust that what they're buying is truly high-quality).

The right approach to this, is to recognize that the question of whether a medicine should be legal isn't a binary question. The FDA shouldn't be forced to say that either a medicine is 100% safe and proven to be unproblematic, or else say that it's dangerous and illegal. If I walk into my neighborhood pharmacy store, and grab some sleep medicine off the shelf, I want to be able to trust that what I'm buying will be unproblematic. But if I need something that has preliminary studies suggesting that it could help me, but is far from being studied well enough to be known to be unproblematic, and there is no better-known substance that can solve my problem, I should be able to ask the pharmacist to escort me into a dark room in the back of the shop, where after having me verbally declare that I know that what I want to buy isn't proven to be safe, and may cause me problems, the pharmacist can sell me what I need.

There would be multiple tiers, ranging from completely untested, to only weakly tested, to having a moderate evidence base, to having a strong-but-not perfect evidence base, to being highly vetted, with each tier indicating an increased ease of being able to obtain the product.

Of course vaccines would fall under this: When new variants of a vaccine are developed, and initial trials show no obvious problems, people should be able to talk to their pharmacists, and after declaring that they understand the product isn't yet vetted to a high standard, be able to obtain the vaccine; while the broader population will wait to see it be vetted to a higher standard. This would also give individuals the ability to use smaller doses of vaccines, or to choose their own vaccination schedule, if they have reason to believe that doing it differently will be in their best interests.

Combining this with my earlier proposal, different vaccine-free zones may signal that they will require vaccines that have been vetted to different degrees: Many zones may only mandate vaccines after they have been thoroughly vetted to the highest standard, others may simply require results that strongly indicate it's safe, and other zones (whose residents consent to such an approach) may even mandate vaccines as soon as it's only moderately verified to be safe. People would be able to pick which type of zone they chose to live in, and thereby decide how they balance the competing risks of vulnerability to variants with immunity escape vs. being affected by unknown side-effects of partially-verified medicine.

Ultimately, this will give each zone the ability to pursue a vaccination policy that it expects will best be able to minimize the spread of the virus while allowing people to live life normally.

Conclusion

While these proposals would not end the pandemic for everybody, they would allow many people to be able to live relatively normal (by pre-pandemic standards) lives insulated from the dangers of the virus. As time goes on, if these proposals succeed in helping people return to pre-pandemic lifestyles safely, the number of people living in such vaccine-only zones will increase, until only those who are the absolutely most uncomfortable with vaccinations would live in non-vaccine-only zones (which should be their right to choose). When that happens, the pandemic would be essentially over for most people.

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27 comments, sorted by Click to highlight new comments since: Today at 5:58 AM

This is because vaccines are the only tool we have that can stop a virus in its tracks without causing undue damage to human productivity and human happiness 

That's not true. Interventions such as improving ventilation or increasing the humidity of the air don't cost human productivity and might even raise human happiness.

Changing laws to make it easier for workers to be ill to stay at home might reduce productivity a bit but raise human happiness.

Vitamin D can also be positive on both.

Upon further reflection, I notice that I am confused. My statement was "stop the virus dead in its tracks", i.e.: single-handedly bring R_0 sufficiently low that infections, instead of growing exponentially, decay quickly within a given population (thereby making outside exposure the only source of continued infections).

As far as I'm aware, this statement is true of vaccines, but is not true of any of: better ventilation, sick leave (since people are contagious usually before they show symptoms), or Vitamin D.

So I stand by my assertion: Vaccines are the only tool in our toolbox that can stop the virus dead in its tracks (as opposed to merely slowing it down)

Vaccines never stopped flu alone in its tracks. It's theoretically possible to get a better vaccine against either of those but the current tech does not seem to be enough to stop the virus dead in its tracks if it's not used in combination with other tools.

We need different words to describe what the polio and measles shots do vs. what the flu and COVID shots do. One of these tools effectively stops [disease/death] and the other may reduce [symptoms/severity/transmission].

That is the only way to let the statement that "vaccines stop the virus dead in its tracks" remain true.

Mike was talking about bringing R0 under 1 and not just about reducing disease/death.

Got it. So the proposed solution on the table is:

  1. Create vaccine that effectively brings R0 under 1 (reducing spread being the key factor here)
  2. Immunize population
  3. Isolate immunized population

If 1 and 2, then we don't need 3, right? 

If 2 and 3 but not 1, then we have something that resembles our current situation, with a lot of people arguing contentiously (rather than productively) over whether 3 is necessary (or helpful) and whether 2 is even necessary (or helpful) given that 1 is absent.

The other question that could provoke argument/contention is "whether the COVID vaccines could have brought R0 under 1 if they were implemented more efficiently." This brings us back to the question of how to evaluate COVID data, because I can see the two movies on the same screen being something like "we could have ended this a year early if you had just taken the vaccines" and "we knew the vaccines weren't going to solve the problem a year before you did."

Thanks for the notes

Vaccine-required zones seem unworkable to me: ours is a highly connected society and it's common for a single household to have members who have jobs / school separated by many miles. Self-sufficiency is completely impossible in the modern world—the closest example is probably North Korea, but that's probably not a model we want to pursue.

There are also immense transaction costs here: there's no area where everyone wants (or doesn't want) to be vaccinated, so implementing this would require massive migration, with immense costs.

It seems to me you've hit on one of the most interesting and challenging things about Covid policy (at both a government and a household level): many of the usual libertarian-ish solutions don't work here, because of the difficulty of keeping one person's choices from impacting everyone around them.

In the post I say:

residents would be able to come and go as they see fit When I said self-sufficient, I didn't mean that nobody ever has to leave, but that ~95% of daily life can be lived without leaving the zone. And that is an aspiration, not something that breaks the proposal if it can't be attained.

If you have a community of vaccinated people, the nice thing is that even if some of them have jobs that put them around non-vaccinated people, first: that person is less likely to get infected at any given point in time, and second: if/when they do get infected, the people they are in contact with will be much less likely to get infected as a result. Both of these combine to mean that someone who lives in a vaccine-only zone will be better-protected than someone who lives outside of one.

I agree that there transaction costs involved, since moving is not a small deal. This can certainly slow down the proposal relative to the ideal, but it hardly seems like a killer argument against implementing vaccine-only zones (as long as it is ensured that implementing the zone doesn't require forcing any existing population to move, i.e. founding in a currently sparsely populated area)

We have existing examples of vaccine-only zones; here's how they're going so far:

Cornell University Shuts Down Campus Due to COVID Outbreak, Despite Vaccine Mandate—Here's How That Can Happen (Health.com, Dec '21, this story was reported in many major outlets)

48 test positive for Covid on world's biggest cruise ship (CNN, Dec '21,"95% on board were fully vaccinated. Of the people who've since tested positive, 98% were fully vaccinated. The total number of cases amounted to 0.78% of the on board population.")

Points worth noting:

  • cases /= serious illness
  • cases /= death
  • unclear: whether outbreaks originated from an unvaccinated person or a vaccinated person
  • more clear: vaccinated people can spread the virus to each other
  • CONTENTIOUS GROUND: whether vaccinated people who contract the virus help speed/spread mutations and variants
  • neither Cornell nor Royal Caribbean could promise a fully vaccine-exclusive area (the linked article notes that the unvaccinated on board the Royal Caribbean ship were children younger than 12, fwiw), but this is about as exclusive as one can reasonably get
  • someone's going to say "what about a walled city," but that is literally (figuratively) what a cruise ship is [edit: ports of call could change this equation, curious whether the outbreak originated on or off ship]

The problem with the real-world situation in Dec 2021 is that we don't currently have an effective vaccine that is FDA-approved (by effective, I mean that can stop the virus in its tracks, i.e. can bring R_0 well below 1) against the Omicron variant, since Omicron has a large degree of escape from the immunity associated with previous variants.

I wouldn't be surprised if a vaccine against Omicron already exists, and I certainly expect it to be developed well within next 2 months if it doesn't exist yet. The main obstacle (as it was with the original vaccine) is to pass regulatory hurdles.

I'm trying to remember if there was an outbreak in a vaccine-mandated zone with Delta. We know that vaccinated people could both contract and spread Delta, and that it can transmit within a "fully-immunized household" (Bloomberg, October '21).

Searching "college campuses Delta outbreak" doesn't get me any stories like Cornell's, at least not on the first page of Google; there are stories of Delta spreading through a relatively isolated facility (nursing homes, prisons, etc.) with caveats that not everyone in that facility is vaccinated. 

The lack of news articles describing "Delta outbreak in fully-vaccinated space" may also reflect the time rollout of the vaccine; maybe there weren't as many "fully-vaccinated" companies, campuses, cruises, etc. when Delta was around.

The larger point is that if vaccines (for COVID or any future pandemic) worked as sterilizing vaccines, you wouldn't need vaccine-only zones -- right? 

I would say, the solution for all such pandemics is a technical upgrade of the Air-Body-Barrier. To whatever virus there might come in future we would need a proper filtering of all the air you breath whenever you are around people. 

Not by masks or anything we know today, but I imagine something like tiny but sealing noseplugs. And those plugs filter all the air you breath for an electrical support of what our vibrissae are not able to do anymore. One way to do this (and i am no expert here) could be a sterilisation by uv light as the air flows into your nose.

There would be many engineering problems on the way, as you would need to make individual passforms, low battery-Issues, people with a cold needing to breath through their mouth. But on the plus side you could ask people to speak less (loud) in public for health reasons.

Highly speculative, i know.

Stuff like this (respirators and maybe even helmets with UV-based filtering) that can end any pandemic already exists.

The problem is that there seems to be little motivation to use these things during a mild pandemic like this one.

I don't think it's a matter of "mild pandemic" it's more a matter of people being severely disorganized and people not wanting to do anything strange and do what other people are doing. 

But why are people still disorganized and think that wearing effective protection is strange? If the mortality rate was a lot higher (like 50% or even 10%) and killed younger people (including children) at roughly the same rate, do you really think that this attitude (here's a glaring example) would still exist? I highly doubt it.

In Germany they make us believe it is quite a medium to severe pandemic. i agree that there is a cost benefit analysis everybody is doing before buying/using such a device. But for me personally i would rather use permanent something like this (https://www.amazon.de/-/en/WoodyKnows-Super-Defense-Nasal-Filters/dp/B00DKX15G2) than wearing a mask whenever entering a building. 

How strongly do those inhibit breathing?

If the policy makers really thought that this was anything other than a mild pandemic, they'd advocate (and probably mandate) for everyone to wear effective PPE. What is actually happening is that most of them (with a few lukewarm exceptions like California) are telling the public NOT to wear potentially more effective PPE. This was the case even after the PPE supply was replenished and before vaccines were widely available. Now that relatively effective vaccines are available, there's even less incentive for this policy to change.

Even in Germany, almost everyone seems to be wearing masks with ear loops. That kind of mask doesn't provide adequate protection, because ear loops don't have enough tension to provide an adequate seal between the skin and the mask. Regardless of rhetoric, official policies and public behavior indicate that almost no one really thinks this is a severe or even a medium-threat level pandemic.

I tired nasal filters a long time ago and found that they restrict breathing too much. Also, I'm not sure how effective the seal would be.

More effective PPE require more training in their use. 

The training is minimal.

When you wear it for a day. For longer periods one also needs to be trained to take care of the PPE. Cleaning, storage, retc.

Half the population have IQ less than 100. You are going to set up training stations or the PPE will fail soon for a large percentage of population.

Mild soap and water can be used to clean the seal, and that's it. Anyone can do that without any special training.

The thoughts in the section about vaccine-only zones is something that I haven't really heard discussed seriously before, but which I think there should be more of a conversation about.

As far as what I say about the FDA, there probably isn't anything useful there that hasn't already been said by Scott Alexander or Zvi M., and I'm sure they say it much better than I did; but I do think improving the role the FDA plays, and giving people more ability to make their own decisions regarding medicine (while making sure they are aware of scientific consensus, and scaling difficulty in proportion to the consensus), is vital to bringing an end to the mess we are currently in.

I don't understand why vaccinated people should prefer not being close to unvaccinated people.

Vaccines provide a high, but imperfect, degree of immunity, so vaccinated people are still at risk of getting sick from unvaccinated people. In a vaccine-only environment, you both are surrounded by people who are much less likely to get infected, and less likely to transmit if they do.

Vaccinated people are also at risk from other vaccinated people.  If vaccinated people are careless and engage in many high risk activities in the enclosed environment, the advantages of vaccination will be reduced. 

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