Is what’s best for me, best for you?

In the movie, “A Beautiful Mind”, there is a pivotal scene where John Nash, portrayed by Russell Crowe, has a eureka moment sitting at a table in a bar with his fellow mathematicians. A beautiful blonde woman and four of her friends walk in, and Nash and his pals debate if the economic theories of Adam Smith are the right way to get her phone number. In unison, they exclaim, “In competition, individual ambition serves the common good.” I suppose this is the way economic theorists discuss dating. It’s the Hollywood way to show how Nash arrived at the spark for his new ideas on expanding game theory and what would come to be known as the Nash Equilibrium. To sum it up and quote from the movie, “the best result would come from everyone in the group doing what’s best for himself and the group.”

With all this extra time to ponder while in quarantine, I had a not-so-novel eureka moment of my own and realized the principles of game theory would be very applicable during a pandemic. As expected, there have been various other articles written about this very topic — from the quite sophisticated and academic in nature, to the more accessible and simplified. So, we will not try to delve into all that. Rather, let’s examine all the possible outcomes related to Covid-19, analyze them further, and then see if we can rank these outcomes and determine if what is best for me, is also best for you, and best for all.

The five scenarios

I can think of at least five basic outcomes:

1. Get infected with Covid-19 and die
2. Get infected with Covid-19 and need hospitalization, but recover
3. Get infected with Covid-19, have few or no symptoms, and recover
4. Never get infected with Covid-19 and eventually get vaccinated
5. Never get infected with Covid-19

I will not try to weight the rankings, as I believe we would all agree dying from Covid-19 is far and away the worst possible outcome, and the others are all well above that one. Even people willing to take on significant risks, either out of financial desperation or because they are frontline workers, don’t want to die, and don’t want to infect their families and risk their lives, too.

The other four outcomes can be thought of as two basic outcomes — I get infected; I don’t get infected. Let’s analyze the get infected scenarios, first.

I get Covid-19

If I get infected and recover, that could be the best possible outcome, as I should have immunity now, and can safely circulate in public. Unfortunately, that is currently not proven, and according to a scientific brief released from the WHO, “There is currently no evidence that people who have recovered from COVID-19 and have antibodies are protected from a second infection.” There is still the good news that I recovered, but it’s not clear what this means to me going forward, if I can possibly get infected again, and possibly be a carrier and infect others. Though the information is incomplete, we must rank getting infected based on what we believe are chances to recover are, and we cannot assume we will have immunity.

Our chances to recover vary, and depend on numerous factors including age and comorbidities. There just really isn’t any simple way to generalize and quantify this risk, so I will not. I think it’s sufficient to say there is a varying degree of non-zero risk that anyone could die of it. The higher that risk, the more proactive behaviors are needed to minimize the chances of getting infected, like social distancing, wearing a mask, and staying home as much as possible.

I never get Covid-19

Based on the analysis so far, never getting Covid-19 at all appears to be the best possible outcome. Ideally, a vaccine comes along, and I can get vaccinated and feel confident to circulate in public. Life can really go back to normal. Though I am optimistic and hopeful that a vaccine is developed, and sooner than later, I have to also recognize that it may not be that soon, or may not ever be possible.

But is it also possible for me to never get Covid-19? Not in any acceptable way, as I am not going to suggest living in a plastic bubble. All I can really do is try, and use the measures we have available so far, like social distancing, wearing a mask, and staying home as much as possible.

Now that sentence should have sounded familiar. Yes, I just concluded the “I never get Covid-19” scenario with the same conclusion, essentially, as the “I get Covid-19” scenario. You may also be thinking that I am going in circles. And I would agree with you.

To break out of the circles, we need a change to the variables, a change to the assumptions we’re forced to make. Even in the “I get Covid-19 and die” scenario, there was an assumption I didn’t even express: unless a cure is found. A cure is an obvious game-changer, and so is a vaccine. But they simply aren’t available yet, and meanwhile I have to try and live each day. As do you and all the rest of us. So can we even determine what’s best for me, what’s best for you, and what’s best for all? Yes, I think we still can, but we need to assess one more aspect: our end goal.

The finish line

Most people have said we cannot have a real return to normalcy until herd immunity is reached. This is the real finish line in this marathon — when enough people have been infected and are immune, or a vaccine is produced, or the combination of the two. Some countries, most notably Sweden, are all in for getting to the finish line as quickly as possible. They have a more open approach than nearly all other countries, and leave the responsibility of following recommendations to the individual. Even Sweden does recognize the detrimental consequences of the virus running rampant and exceeding healthcare system capacity, i.e. Italy in March. But they don’t want to mandate lockdowns and other behaviors. It’s an attractive approach, for sure. A lot of its success, in terms of keeping fatalities down, will depend on how well they are able to protect the most vulnerable populations, such as the elderly.

In my state, Connecticut, that has not gone so well. In the latest report on nursing home surveillance, there have been 958 confirmed Covid-19 deaths, and another 291 “probable” deaths, for a total of 1,249 deaths. For our state as a whole, there have been 2,257 deaths — more than half are nursing home residents. The impact of the nursing home deaths is simply staggering, and the implications on the fatality rate are obvious. And this has happened during the lockdown, in a state where nursing homes were closed to visitors since March 9, even earlier than schools were closed.

The whole premise of herd immunity is based on two important assumptions: the infected gain immunity or a vaccine will eventually be available. We already know that neither seems to be guaranteed. But I think there may be an alternative finish line that we need to acknowledge and should plan for and work towards, where we can’t count on herd immunity, or at least any time soon. It has been discussed in the media and by the political leaders and medical experts as the next phase known as “containment”.

Containment, as the word implies, simply means we keep any outbreaks contained. This is where testing and contact tracing come into play. These strategies, similar to the mitigation strategy of social distancing, are proven and already used for some viruses. Covid-19 has all too often been compared to the flu, and usually incorrectly compared. Let’s instead compare it to Ebola. Yes, Ebola is far, far more lethal, but is also not as contagious as Covid-19. They are not even caused by the same virus family. But Ebola also has no cure, has no vaccine, and yet we’ve managed, so far, to not have a pandemic, or even a wider epidemic. There is essentially one strategy to keep Ebola at bay: containment. Luckily, Ebola is considerably easier to contain than Covid-19, primarily because it has a short incubation period, and the infected become so sick, that they are not circulating and spreading the disease.

That is not the case with Covid-19, and is why it has proven to be so difficult to contain so far. As we’ve now heard many times, carriers are contagious while they are incubating, or presymptomatic, and this period may last days or possibly even weeks. Or carriers may be asymptomatic altogether, and never show any symptoms, and still be contagious.

Besides the current protocols of wearing masks, and staying apart, there may be another way. As with standard containment, it relies on testing, but this would require testing to a whole new level. We need an accurate, fast, cheap test, that we can use at home, and use regularly, perhaps as often as every few days, depending on how often you are going out. Containment depends fully on identifying the infected and limiting their exposure. If we can do this with Covid-19, we may be able to allow for far more easing of restrictions. Of course the type of testing I am describing would be very difficult to develop, and may not even be feasible. But there are at home tests being developed, and at least some others have recognized that this could be an important component as a way to at least partially return to normalcy. So much of what we need to do right now is based on the premise that we don’t know if we ourselves are infected, so we must behave in ways that assume we are. Take away that unknown with frequent testing, and we have another game-changer.

What’s best for me?

We can simplify our three scenarios as: get Covid-19 and die, get Covid-19 and recover, or never get Covid-19. I propose the best thing that can happen for me is to never get Covid-19. Is that also the best thing for you? If I never get it, I can’t infect you. If you never get it, you likewise can’t infect me. So if neither of us get it, is that best for all? It sure feels that way to me.

I recognize that I can’t fully control if I get Covid-19 or not, and all I can do is try. Until the game-changers come along, and I really hope they do come along, I will be wearing a mask in any shared spaces, keeping a safe distance from others, and staying home as much as possible. This is the best thing I can do for me, for you, and for all of us. Oh, and I’ll still be washing my hands a little more than usual.