We all know that the official response in this country to COVID-19 has been, at best, poor, at worst incompetent.
Too late to close, too late to declare the situation an emergency — resulting in at least 65,000 deaths over and above a projected burden.
Too disorganized and uncoordinated a response. Messages not synchronized, leadership belittling the seriousness of the hour, decrying public health measures that are effective — promoting unproven, even dangerous remedies.
Too quick to re-open, absent adequate systems to follow and monitor potential outbreaks. Too slow to adequately alleviate economic distress, particularly for those with lower incomes, already put at risk by weaker public or private healthcare.
But the truth of the matter is that we all know one other truth — case numbers will once again rise (in some states, that is already happening), in their tracks a lagging rise in new deaths. The current rises in states like Arizona may derive from early re-opening. Later surges are possible once we return to a more indoor life as fall comes and winter beckons.
Certainly, it also true that a repeated national (or statewide, state-by-state) lockdown is unlikely — at least, not in the form most recently practiced.
So, the best question to ask might be how to improve on our response to COVID-19. Because, it is clear, this pandemic is not under control in the US, and is likely to be with us for a long time.
Over at STATNews there is a recent article by Sharon Begley & Helen Branswell that gets right to the heart of the question — How the world can avoid screwing up the response to COVID-19 again.
While they title the piece as a way to improve worldwide response, it is clear on reading that many of the prescriptions they then lay out have a strong “buck up America” flavor to them.
Before we get to the suggested response improvements Begley and Branswell first lay our how badly things were handled in the US and elsewhere.
“I’m still getting over my shock at how badly this was handled,” said epidemiologist Stephen Morse of Columbia University, who helped create an international network to detect and monitor disease outbreaks. “After all the work and all the exercises everyone did, it’s heartbreaking to see how badly the ball was dropped.”
So, what did STAT do to prepare this best practical practices piece? They sought advice, from 11 experts. Asking them avoid recrimination, point to solutions, identify lessons learned or lessons learnable.
STAT therefore asked 11 experts in infectious disease, epidemiology, and pandemic preparedness how to avoid the mistakes, poor decisions, and incompetence of this spring. We asked them not to invoke magic; advice like “develop a vaccine” is obvious but not very helpful. We also asked them to look forward more than backward; we don’t want to relitigate things like the monthslong shortages of Covid-19 diagnostic tests, President Trump’s cheerleading for unproven (and potentially harmful) treatments, or the demonstrably false assurances by the White House that anyone who wanted a diagnostic test could get one. The experts did take some peeks into the rear-view mirror, since understanding past mistakes can help us avoid repeating them. But for the most part they focused on how to do better next time.
What they came up were some fourteen response improvements.
One — Prioritize early warnings
Including the use of alternative measures known to give earlier indication of an emerging outbreak, for which actual symptomatic patients have yet to be identified. Such as testing of wastewater for viral genetic fragments, shed through fecal matter.
Two - Pay attention to small numbers
Once cases begin rising exponentially, finding them and their contacts becomes nearly impossible. “If you wait for big numbers, it will be too late,” said Paul Biddinger, an emergency preparedness expert and physician at Harvard T.H. Chan School of Public Health.
In particular they suggest that smaller case growths should be evaluated (on the basis of tracing) — a cluster coming from a large gathering is more troubling than a similar number traced to a smaller gatherings (say 10 or fewer people).
Three - Act fast
If an exponential increase is in the cards, dithering around as New York and other places did in March will only make history repeat. Imposing business restrictions and other social distancing measures two weeks sooner than most U.S. states did could have averted tens of thousands of deaths, Columbia University scientists calculated.
But ...
Four — Act fast strategically
Begley and Branswell suggest that, while it is Was not just the White House that dropped the ball. Some locations (like New York State) also acted like deer in the headlights — I’d argue that much of that also arises from piss-poor CDC / White House direction. But it is also possible that some locations imposed lockdowns ahead of schedule.
There is also the factor of willingness and capability to engage in renewed nationwide (or generalized statewide lockdowns) as we tried to do in the March and April period.
Thus, their presented response improvement consists of localized, targeted, measured response — up and including suspension of restaurant dining and large gatherings in affected areas. Which might be limited to counties or cities.
Five — Do a way better job in minority and high-poverty communities
Given the higher fatality rates experienced by minority and high-poverty communities in the US, the need to improve COVID-19 response in several ways amongst these communities could not be more clear.
This category of needed improvement lacks concrete suggestions, pointing instead to lessons learnable.
Begley and Branswell call for avoiding errors such as depending on drive-through testing facilities (in locations where most people were otherwise dependent on public transit, and car ownership was lower). They suggest we may already be baking in related errors by leaning on cell phone tracking apps for contact tracing (which demands a cell phone, which some unemployed or lower income cohorts may lack). Also, our essential workers in restaurant or grocery employment may be forced into situations where simple face coverings are unequally demanded, perhaps even frowned upon.
On that last point, it is unclear what could be done to significantly improve matters, until that is we have rational exemplary behavior from the administration on down.
Six — Don’t hide the truth or pretend to have more knowledge than you have
Here they do a good job of chiding the ver-changing and poorly communicated protocols from the CDC (let alone the White House) on the merits of wearing masks, of any type.
Early on, the Centers for Disease Control and Prevention told Americans they did not need to wear face masks.
This, they say, was mistaken on two fronts. Firstly, it ignored others experience (in Asia in particular) which showed that simpler face coverings were mutually beneficial when all wore them, in stemming droplet transmission from coughing and sneezing. Secondly, it conflated the need for preserving N95 or P100 respirator stocks for medical use with use of more widely available cloth or surgical mask-like coverings.
Both failures damaged their credibility. Once experts acknowledged the importance of preventing virus transmission, the pandemic was out of control, and Americans questioned both whether experts knew what they were talking about and whether they could be trusted to tell the truth. Adding insult to injury, many employers — even hospitals — prohibited employees from wearing masks because doing so “would upset customers/patients.”
Seven — Do social distancing smarter
And, therein, what is being asked for is to use this period of time to determine which of the social distancing measures were the most effective. Did 6-feet distancing accomplish the same degree of transmission reduction as that from hand washing, or mask wearing? Emphasize in response to the inevitable next flare-ups and spikes use of those measures proven utile, set aside those proven futile.
They cite Japan, which obtained similar (better, really) levels of transmission control by shutting down the schools, while businesses and workplaces stayed open — likely due to better adoption of mask wearing, hand hygiene and lack of hand-shaking.
Eight — Take mild cases seriously
The best way, they argue, to take mild cases seriously is to actually, you know, find them. In other words testing, testing, testing. Testing where the criteria-based gating is thrown (comparatively) wide open. Testing where the cost constraints are completely alleviated. Testing done as a routine matter of course. Diagnostic, and serological. Testing correctly and routinely reported.
Nine — Beef up the National Stockpile (and make it obvious that this is a Federal Resource to help the States)
Shorter — get Kushner out of the way and put logistical experts in charge of this.
Ten — Don’t expect patients to figure out isolation on their own
“Next time, we have to provide infected individuals with strategies to effectively isolate at home to reduce the risk of spreading the virus within their households,” said Chowell. Although much of the transmission has occurred in public settings, “we cannot ignore the role of household-based transmission particularly among the most vulnerable, who are more likely to share small living spaces with many other people.” If the outbreak returns in force (and even now), provide isolating households with PPE and other support.
We can learn how to from cities like Boston who set aside isolation housing for those without sufficient independent space at home to truly self-isolate, from society, and, critically from family members.
Eleven — Get serious about staying on top of the virus
This might sub-headed “Listen to the experts” — particularly about the merits of proven protocols. Like
- The need for contact tracing
- The negative outcomes of insufficient contact tracing (no concerts, no return to any larger gatherings)
Twelve — Stay humble, be flexible
There have been surprising results in the pandemic response, some positive. The extent to which even poorly or inadequately imposed distancing and hygiene measures reduced transmission rates was one positive surprise. Some modeled growth rates proved woefully wrong and too optimistic, others were closer to the truth and more valuable.
Still, the over-riding lesson is that we still have much to learn. In particular we may be forced to live with a more flexible approach to this beast.
Reject false dichotomies like “open or close,” Frieden said. The economy and society were never fully closed, and won’t be fully open until there is a vaccine. Rather, it may be like a light on a dimmer switch — brighter at some times and in some places than at other times or in other places.
Thirteen — Resist magical thinking
As countries have driven down their outbreaks through measures unlike anything attempted in modern times, some experts are worried magical thinking is again taking root.
:: ::
... we’ve never watched a coronavirus pandemic unfold. Will summer weather really slow spread or will the easing of restrictions bring an immediate resurgence of cases? Will there be another — a worse? — wave in the fall? Do we face years of waves, until the world can be vaccinated?
I would say some parts of that last set of questions are readily answerable right now. If the warmer weather alone were the magic bullet for ridding the world of COVID-19 (if only for a season or two) then we should not be seeing high rates of infection in countries such as Brazil, or India, or Mexico. But we are. So I believe we can safely conclude that a coronavirus pandemic does not follow the sinus wave profile of growth and retreat typical of the HnNx flu viruses.
Anyone betting on such weather-derived rescue is indeed indulging in magical thinking.
Fourteen — Communicate better
In this respect, having Trump thoroughly disinterested in opening his gab to spew forth his latest King Clorox and the Mighty Hydroxychloroquine hour of Power helps. But it wasn’t just Trump that missed the mark on messaging. At one early point the CDC (and Fauci) both were uttering guidance that turned out to be way off the mark. At the time it was originally stated.
Clear consistent messaging is vital.
The public needs clearer information, even when that information is merely an acknowledgement that some facts about the virus remain unknown and the course of the pandemic isn’t currently predictable. And it should be steeped in science and fact, not politics.
There — some fourteen areas offering opportunities for an improved COVID-19 response, several with ready-made, proven protocols. Some already in use.