Three Paths to the Future

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Three Paths to the Future

By Marin GjajaRich HutchinsonAdam FarberAmanda Brimmer, and Dan Kahn

The world is in transition. Many countries have flattened—and, in rare cases, some have nearly eliminated—the curve of coronavirus infections and begun the precarious work of resuming economic activity.

Transition implies progress, but it comes with the risk of backsliding into successive waves of disease, W-shaped recoveries, and further economic and human devastation.

We have characterized the recovery from the coronavirus into three phases: flatten, fight, and future. The future will not arrive until a vaccine or people’s natural resistance creates herd immunity or until an effective treatment emerges. In pursuing this end state, governments have made different policy choices, strategies, and tradeoffs between health outcomes and economic and societal costs—a discipline we call “epinomics.”

Within the fight phase, three broad strategies for fighting the coronavirus and restarting the economy have emerged: crush and contain, flatten and fight, and sustain and support. (See Exhibit 1.)

While it’s a continuum, the speed with which coronavirus interventions are implemented and their stringency are key factors that distinguish each strategy. (See Exhibit 2.)

Crush and Contain

A small subset of governments moved quickly to impose measures to contain the spread of the coronavirus, and, in some cases, they have nearly eliminated local transmission. In South Korea and Taiwan, the governments rapidly imposed restrictions and deployed comprehensive virus-monitoring systems that included testing, tracking, and contact tracing. These systems had been built in response to past epidemics. The governments also quarantined hot spots to avoid a complete countrywide shutdown. By acting early, South Korea and Taiwan kept the number of cases below the limit of their virus-monitoring system’s capacity, rather than below the limit of their health care system’s capacity. By comparison, New Zealand used early countrywide lockdowns in combination with rapidly expanded virus-monitoring systems to limit community spread. China also had success with this approach, but the duration and stringency of its lockdown in Hubei would be challenging in many other countries.

The crush-and-contain strategy may still be an option for a small minority of countries. Costa Rica, for example, declared a state of emergency in late March, and it has had fewer than 20 cases a day since early April. Now, Costa Rica is beginning to reopen. Other countries that were unable to fully contain the spread of the coronavirus early diligently put themselves in a position to try to migrate to a crush-and-contain strategy. Israel, for example, was averaging hundreds of new cases a day in mid-April. After considerably scaling the capacity of its virus-monitoring system, the country’s share of positive tests fell below 1% by May 18, and its seven-day average of new cases fell to 20 (fewer than 2.5 new cases per 1 million people). This combination of widescale testing and low case counts may allow Israel to become the next South Korea. (See Exhibit 3.)

Having had success in effectively eliminating the coronavirus, these crush-and-contain governments are now focused on implementing strict border controls and testing at major points of entry to keep new cases to the absolute minimum. In effect, each government’s goal is to restore its economy within a walled society. It is not a coincidence that two of these examples are islands and two (South Korea and Israel) are virtual islands given their relationships with their neighbors.

But a crush-and-contain strategy still poses ongoing challenges and tradeoffs related to international trade, travel, and tourism, all of which are important economic engines for many of these governments. Tourism, for example, directly and indirectly accounts for 10% of New Zealand’s economy and supports nearly 15% of its workforce.

Moreover, governments must remain vigilant against new waves of infection. In early May, South Korea closed bars and nightclubs in Seoul after the discovery of 40 new cases linked to one patron. And in mid-May, China imposed a citywide lockdown in Shulan, which is near the Russian border and home to about 700,000 people, after an outbreak.

Flatten and Fight

The vast majority of countries—for example, most nations in Europe, South America, and North America, including the US—were unable to contain the initial coronavirus outbreak. Either conditions such as population density and the prevalence of multigenerational housing were too challenging or their restrictions were too late and too little to stop the spread. As a result, these countries pursued a broad strategy of flatten and fight. Faced with the exponential growth of case counts, these countries instituted society-wide social distancing and lockdowns to avoid a public health crisis.

In practice, flatten and fight encompasses a variety of prerequisites, including expanding the health care system’s capacity, protecting the vulnerable, monitoring the coronavirus, and crafting clear and consistent guidelines for opening and reclosing sectors of the economy. It requires the cooperation, compliance, and patience of residents, many of whom have lost their jobs.

Flatten and fight is necessarily a long and uncertain approach to fighting the coronavirus. The goal is to reopen the economy in phases without overwhelming the health care system. But, because community spread in many of these countries exceeds the capacity of the virus-monitoring system, they face a meaningful risk of future exponential growth in case counts and the need to institute localized lockdowns. In effect, these countries are hoping to find an optimal set of epinomic policies that balance health and economics while building up virus-monitoring capacity, and they are holding out for the introduction of successful treatments and vaccines. Only a few countries, such as Germany, have been successful at creating the required infrastructure, and we are still in the early days.

Unfortunately, many developing markets lack the health care or virus-monitoring infrastructure and income or food security required to outlast the coronavirus. For example, Brazil, with the greatest number of cases after the US, is emerging as one of COVID-19’s new epicenters. We expect that other developing markets are not far behind. With a weak virus-monitoring infrastructure in many of these countries, we may only fully learn of their struggles after the fact.

Finally, the epinomics of flatten and fight are inherently expensive. Health outcomes are an ongoing concern because the coronavirus is still out there, and unemployment and economic activity take huge hits. Countries that pursue the flatten-and-fight strategy must aggressively pursue de-averaged policies aimed at regions, states, and even municipalities to minimize health and economic tradeoffs. The focus on execution needs to be relentless. This strategy will test the resolve of governments and society as both seek balance in health and economic outcomes. In fact, these challenges suggest that many countries are likely to seek another path in the months to come unless a vaccine or game-changing treatment arrives.

Sustain and Support

Given concerns about the sustainability of a flatten-and fight-strategy, Sweden is emerging with an alternative model: sustain and support. The Swedish approach is built on selective and largely voluntary restrictions to protect vulnerable population segments, such as the elderly, while keeping much of society and the economy open. The goal is not so much to limit community spread as to manage it in order to build herd immunity among the young and healthy.

International interest and speculation surround the viability of Sweden’s strategy, but it is too early to draw definitive conclusions. On health outcomes, as of early May, Sweden had from three to seven times the number of deaths per capita as its Nordic peers. The country has also struggled to contain the coronavirus in nursing homes. The percentage of COVID-19 cases in Sweden in people age 70 or older is double that of Denmark and triple that of Finland and Norway. On economic outcomes, mobility data from May 16 suggests Sweden’s residents are commuting, shopping, and taking public transit about 15% less, on average, than they normally do. Norway has shown a decline in mobility similar to that of Sweden, while Denmark and Finland are seeing sharper declines of 25% and 35%, respectively. Yet it is too early to assess the economic impact fully. We will only be able to judge the cumulative impact over time.

Against that backdrop, the current number of cases has not completely overwhelmed the Swedish health care system. And it may be that, because the approach is less onerous for the population as a whole, it is more sustainable and likely to maintain citizen trust and support over time. So far, survey data suggests that most Swedes support the government’s approach.  

Could the Swedish model work elsewhere, and how might it be improved? For example, to what degree does it depend upon the high levels of social cohesion and trust in government typical of that country? And how realistic is this approach in societies with less favorable demographics—for instance, with a smaller share of single-person households and a larger share of multigenerational households and higher levels of chronic diseases? Would a similar strategy that actually protected the vulnerable be successful broadly or in some locations? Regardless, how can countries learn from Sweden’s approach?

The Path Forward

National strategies cannot be the only answer, especially in large countries, such as India, Russia, and the US. There are still opportunities at the state or regional level to impose a crush-and-contain strategy. Rhode Island, for example, has among the most ambitious virus-monitoring plans in the US, a necessary precondition to implement it. On the other hand, the small state is intricately linked to the larger New England economy; walling off its economy and restricting the movement of people across its borders would be challenging.

What is clear is the imperative to act swiftly. Once infections reach a certain level, a stringent lockdown and a dramatic expansion of virus-monitoring system capacity is the only way out of a flatten-and-fight strategy. Unfortunately, that option is not politically or economically possible in many countries or areas. Given the instability of flatten and fight, the next few weeks and months are critical for countries and regions facing a restless public, the possibility of successive waves of infection, and stagnant economies. Finding better strategies and policies is an urgent research agenda for most of humanity. We need to invent the new field of epinomics in real time.

In the coming weeks, we will examine these strategies and pressing questions through an epinomics lens as an aid to governments and the public sector. (See the sidebar “More Questions Than Answers.”) In the meantime, we welcome discussing ideas on this topic. Please share your thoughts with us at

More Questions Than Answers

The uncertainties about which strategy to pursue are manifold. We are still learning the health, economic, and social costs of each. We also recognize that the success and costs of each strategy are dependent on the regional, demographic, public health, economic, social, and political contexts. Given that we estimate that a successful globally scaled vaccine is at least 12 months away and perhaps much longer, we believe that governments must urgently adopt six best practices. (See the exhibit.) 

They must also explore these practices by answering a set of questions at a high level of detail. For example:

  • What new practices are necessary to find the best balance in limiting the number of social interactions and allowing the economy to remain healthy?
  • What are the best guidelines for safer interactions—for example, at school and in the workplace?
  • What is the best approach for expanding the capacity and capability of virus-monitoring systems that integrate testing, tracking, contact tracing, technology, isolation, and quarantining?
  • What are the most effective ways to identify and protect the vulnerable—for example, the elderly, the chronically ill, and those housed in crowded living institutions such as nursing homes, mental health facilities, and prisons?
  • How should societies plan to build up their health care system’s capacity for any new waves of infections while they fulfill their day-to-day functions?
  • What is the fastest and most efficient path to an effective and safe vaccine, without which we may be living with the coronavirus for years to come?