»Zero Covid«: A rapid and comprehensive end of the pandemic is possible

Europe is groaning under the second wave, the lurching course of politics has brought us a second lockdown of unimagined duration. The “Zero Covid” strategy, which was successfully applied in the Asia-Pacific region, shows that there is another way. They were advised by Yaneer Bar-Yam, among others.

German version

We are more than a year into the coronavirus pandemic and it could not be clearer which strategies have succeeded against the virus and which have failed. Now that we are faced with a faster spreading mutated strain of coronavirus, it is even more imperative that those countries that are failing start to learn from those that are succeeding.

My country, the United States, lies squarely in the failing column: we are suffering from record high COVID-19 infections and are likely to face significant death and disease as we wait several months for the full roll-out of vaccines, and the suffering could very well be compounded further by the new coronavirus strain identified in the UK.

But even Germany, once considered within Europe as a model for its COVID-19 response, has not fared well in comparison to many Asia/Pacific countries that opted for a »Zero Covid« strategy.

Thailand, for example, has a population of 69 milllion, but has only suffered about 60 deaths from COVID-19 since the start of the pandemic. Meanwhile, Germany — population 83 million — has had more than 26,000 deaths. What’s more, Germany is currently locked down, while life in Thailand is close to normal.

Residents of New Zealand, Australia, Taiwan, and Vietnam, are also enjoying something very close to normal life because their governments made the right decisions: they chose a »Zero Covid« strategy. This, even with the need to respond to occasional small outbreaks.

In March, I played a part in advising Australia to adopt a Zero Covid strategy when I spoke with the country’s YPO business group regarding how best to eliminate Covid-19 and limit damage to Australia’s economy. After our meeting, YPO Australia wrote a letter to Prime Minister Scott Morrison (attached). They wrote:

We are writing to you as members of the Australian business community who are seriously concerned about the health and economic impacts of the COVID-19 pandemic. Our organisation’s businesses represent over 10% of Australia’s GDP, and we employ hundreds of thousands if not millions of Australians across all industries including healthcare, retail, transport, technology, property & construction, financial services, hospitality and education.

As an organization, we urgently request the Government to listen to the advice of Yaneer Bar-Yam whose guidelines have been followed successfully by Singapore, South Korea, China (belatedly) and Vo (a town in Italy) and more recently by President Trump.

We call on the Government to implement an immediate four week hard and fully enforced lockdown of Australia to avoid catastrophic public health outcomes and severe economic consequences.

If there is not a hard lockdown, the economic cost and loss of life will be exponentially higher. This is a choice between a short, highly effective lockdown or a very extended community driven and mostly ineffective rolling lockdown. It is a choice between sharp but manageable pain and sustained cumulatively much larger and unmanaged economic pain.

We urge and strongly encourage that the Australian Government take the advice of Yaneer Bar-Yam on which the above is based on rapidly developing its policy response to the Coronavirus crisis, and we can facilitate an introduction to him personally within the next 24 hours.

I am pleased that this letter was said to have been influential in Australia, though I regret that President Trump didn’t do more than symbolic implementations of my recommendations . The current conditions in Australia are outstanding. Even where localized outbreaks take place, they are being stopped quickly and the return to normal is rapid.

Australia, along with New Zealand, Taiwan, Vietnam and Thailand, have effectively eliminated transmission of COVID-19 through the »Zero Covid« approach. European countries and sub-national regions – which have so far misjudged the Zero Covid strategy to be too hard, too costly, or simply impossible –can still change course and eliminate Covid-19 before the full rollout of a vaccine.

Since March, it has become clear what elements are key to a successful Zero Covid strategy. I would like to highlight six lessons from the Asia/Pacific success stories that should be applied everywhere:

1. Target zero cases and treat every single new infection as a national security threat. (In contrast, in the United States and Europe, authorities aim to keep COVID-19 cases at a »manageable level.« Unfortunately, a permanent »soft lockdown« is required to keep the »manageable« level of transission of cases from exploding into exponential growth, and no country has been able to stomach a permanent soft lockdown.)

2. When community transmission first appears, impose short, strict lockdowns – combined with masks, tracing, and ventilation – to get to zero cases. (In contrast, in the United States and Europe, authorities often wait to impose restrictive measures until hospitals approach full capacity, and then often only impose »soft lockdowns.«)

3. Isolate infected individuals and their contacts in »quarantine hotels« or specialized facilities. (In contrast, in the United States and Europe, authorities advise infected individuals and their contacts to self-quarantine at home. These individuals then infect their cohabitants or violate quarantine and infect others.)

4. Prevent importation of new cases through mandatory quarantines on travelers from »red zones.« (In contrast, in the United States and Europe, most travelers from places with active transmission can avoid mandatory quarantine if they provide a negative PCR test, which has a high false negative rate. And »mandatory quarantine requirements« are typically not strictly enforced.)

5. Sub-national regions reopen through »green zone« strategy, in which COVID-free »green« zones reopen while restricting travel from »red zones.« (In contrast, in the United States and Europe, regions reopen before transmission is eliminated. When »green zone« status is achieved in sub-national regions, authorities do not protect these through travel restrictions.)

Many of those in Europe and the United States who accept that getting to zero Covid is possible claim that it could not work in the West because it »too costly.« . However, when community transmission is taking place, the set of actions required to prevent exponential transmission growth is both costly and neverending. Without economically prohibitive measures, another Covid wave is guaranteed to occur, requiring yet greater costs to suppress, as well as the additional loss of health and life.

The larger the number of cases per day, the more costly it is to contain the virus. Why would any country not invest in the short term to reduce new cases to as low a number as possible? Then they could control the virus with fewer social, economic, and health costs for the remainder of the pandemic. Why not get to zero community transmission, so that the economy can truly open up again?

Another argument against a zero COVID strategy is that the region may import cases. Fair enough. But containing imported cases is less costly than containing both imported cases and containing community transmission. How much less costly depends on the rate of travel into the region and the quality of testing, contact tracing, and quarantine policies at the border.

For reasonably well-implemented policies, zero community transmission means life within the region can go back to close to normalcy. Normal social and economic activity in retail, restaurants and bars can be restored. Restrictions on international travel are a much smaller price to pay than the cost of domestic restrictions to prevent transmission. Vigilance is required: an outbreak may arise, but just as with firefighting, it is less costly to impose such measures sporadically than battle continuously. Outbreaks can be localized, so that only a small part of the country or state is affected.

Perhaps the most common argument against the Zero Covid strategy is that it is simply not possible to eliminate community transmission. But if it is possible to get from 1000 to 100 cases per day, and from 100 to 10 cases a day, why is it not possible to get from 10 to 1 and then 1 to 0 cases per day? It is simply a matter of patience. Indeed, the smaller the number of cases, the easier it is to proportionally reduce as more testing/contact tracing/quarantine resources become much more effective and can be devoted to the few remaining cases. And if it is impossible to eliminate Covid-19, how have so many countries already succeeded in doing just that?

In the summer, many countries, including Switzerland and Austria, reduced their confirmed numbers of cases per day to less than 20, as did multiple states in Germany, but then opened up. For a while afterward, the number of cases remained low. But things began to change once the quarantine effects of the previous lockdown wore off. Just as the letter to Australian PM Morrison predicted, a second wave was inevitable. What is striking was how close some European countries and German states were to elimination: if it was possible to hold the number of cases per day approximately constant for a significant period amount of time, then it logically follow that just a slightly higher level of social distancing would have caused case numbers to exponentially decline, eventually reaching zero.

Eliminating community transmission does have higher short-term costs— stricter social distancing measures must be maintained for longer. But given how maintaining zero community transmission is less costly than the alternative, and given that mass vaccination it at least 6-12 months away, it is worth a short-term investment to reduce long-term economic costs, and this aligns with saving lives and averting long-term health effects.

Furthermore, getting to zero transmission within a locale is far faster than doing so in an entire state or country. A »green zone« approach, in which locales can open up one by one, with free travel allowed between disease free regions, is optimal. Zones help not only themselves but also their neighbors, their country, and the world: the attraction of gaining the right to travel to a green zones incentivizes red zones to improve. If an imported case causes an outbreak, most zones remain economically open at any given point in time.

It is surely tempting to lift social distancing measures when transmission is low, just as it was tempting early on not to impose them. But such thinking is short-term, based on the small chance of an individual being infected when spread is low. Taking a longer-term view, it is less costly to act sooner than later, and less costly to eliminate community transmission and combat importations than to constantly maintain measures necessary to prevent more waves and yo-yo restrictions.

Yaneer Bar-Yam is the founder of endcoronavirus.org