Finding Normal (part 3)
The conclusion in a series on COVID-19
(Reminder : all underlined text links to source articles)
This is part 3 of the third installment in a series on COVID-19. Click below for the previous pieces:
As we examined in the parts 1 and 2, the road to normal begins with a plan that contains the following broad steps:
Step 1: Calm the anxiety
Step 2: Fortify your defenses
Step 3: Attack
We previously explored the key to Step 1 which is to implement "force majeure" economic policies to calm the anxiety that has resulted in an outcry to prematurely reopen the economy even as 20+ states continue to have increasing COVID-19 case numbers.
The false choice of sound public health policy vs "re-opening" the economy has become the centerpiece of our national debate regarding COVID-19. This framing of the issue has fundamentally arisen because we failed to implement force majeure economic policies alongside the social distancing stay at home orders.
This is a national economic policy failure not a public health policy failure. Unfortunately, the economic pain is what is causing many Americans to push back against public health policies because they view it as the reason for their economic suffering, when in fact it would have been possible to address our health concerns without inflicting economic losses.
From a public health perspective it is important to realize that as of May 27, 2020 only Illinois had met all federal criteria required to move to phase 3 for reopening the state - by contrast NY just completed phase 1 requirements.
Quelling economic anxiety, and thus preventing a premature opening of the economy, would in turn alleviate anxiety expressed by burned-out healthcare workers who are concerned that a second wave of COVID-19 patients will further exacerbate an already strapped healthcare system.
And for those of you who think I'm being overly pessimistic about COVID-19's severity as we move forward, consider that Texas is experiencing its largest spike in coronavirus cases to date.
Included in the types of gatherings that have resulted in COVID-19 spikes are graduation and prom related celebrations.
In this piece we'll focus on Steps 2 and 3 of the plan on returning to normal: fortifying our defenses, and going on the attack.
Where's the Spoon?
As I've followed coverage of COVID-19 over the past month, I've been constantly reminded of a scene from Eddie Murphy's classic film "Coming to America." At the end of the film, in the barbershop, Murphy disguised as one of many characters he portrays in the film tells a simple joke:
"A man goes into a restaurant, and he sits down, he's having a bowl of soup and he says to the waiter, waiter come taste the soup.
Waiter says: Is something wrong with the soup?
He says: Taste the soup.
Waiter says: Is there something wrong with the soup? Is the soup too hot?
He says: Will you taste the soup?
Waiter says: What's wrong, is the soup too cold?
He says: Will you just taste the soup?!
Waiter says: Alright, I'll taste the soup - where's the spoon??
He says: Aha. Aha!"
And so it is with COVID-19 and how we begin to return to normal as well as reopen the country. What does this mean? In the previous installment I introduced you to Bert who owns a bar. Let's say Bert wants to be able to reopen his bar asap and he doesn't want everyone to have to wear masks or socially distance. Well, then Bert needs to know that every person in the bar either has tested negative for COVID-19 or positive for the antibodies. Bert would gladly sign-up for that, but here's the problem...where are the tests?
Bert is asking us how he can reopen - preferably without masks. We tell Bert he can reopen so long as he can be sure of the COVID-19 testing status of all the people in his bar (though we'd still recommend the masks). Bert says he'll make sure everyone's COVID-19 status is known so we don't need the masks, because the masks are bad for business. But where's the spoon? Where are the tests? Just as the problem with the soup in Coming to America was the lack of a spoon, the problem with our desire to reopen the country and get back to normal is our lack of tests.
Similarly, we introduced you to Ernie, Bert's good friend who works in the ER. Ernie reluctantly says OK, fine reopen the country but give me the PPE, hospital beds, and hospital staff I need to take care of the patients when they start rolling back in. He says we need this to ensure the safety of our staff, our patients, their families, and to ensure that the system doesn't bend or break as the case numbers go up.
But where's the spoon? Where are the N95 masks? We don't have them. Where are the extra hospital personnel for the long COVID shifts? Where are the extra beds so the hospital can treat non-COVID patients along with the COVID ones? Unfortunately we don't have any of it, so Ernie can't do what he needs to do in order for the world to reopen properly and for us to get back to normal quickly.
Unfortunately we're caught between two movies right now when it comes to spoon metaphors. Eddie Murphy is asking where's the spoon, and all we're left with is the Matrix telling us there is no spoon.
But we really need that spoon or we can't have the soup! No soup for you!
The purpose of flattening the curve was two-fold: To reduce / delay the overall spread of the virus and, more critically in the short-term, to prevent a collapse of the healthcare system.
Since each state, as well as country, has a different healthcare capacity, the phrase overwhelming the system means something different around the world.
In the US we have a few statistics working against us. For one, we rank towards the bottom of the list on hospital beds per capita and ICU beds per capita so our system is more susceptible to collapse than that of Italy or South Korea.
The USA has a total of 2.8 hospital beds per 1000 people. By contrast Italy has 3.2 beds, China has 4.3 beds, and South Korea has 12.3 beds. Without a lock-down, as it were, it is estimated we would have needed 60 hospital beds per 1000 (over 20 times more than what we have available).
To see how this plays out in practical terms, Austin, Texas is now on the verge of reaching its hospital capacity trigger.
In addition to a deficiency in hospital bed capacity, we also have a severe shortage of supply of PPE. That's right, the PPE shortage still exists and it is still real. For example, the State of Illinois has not had an inventory of isolation gowns available for distribution through its department of public health for the past month, they have no N95 masks to distribute and instead are distributing KN95 masks procured from suppliers overseas. To date, the FDA and CDC still encourage the reuse of N95 masks (which were not intended to be re-used) because the shortage of PPE is real.
Former Biomedical Advanced Research and Development Authority (BARDA) head Rick Bright said last month that his warnings about medical supply shortages were ignored by his superiors.
Bright said he thinks the supply shortages and the delay in production increases cost lives."I believe lives were lost, and not only that, we were forced to procure these supplies from other countries without the right quality standards," Bright said.
"So even our doctors and nurses in the hospitals today are wearing N95 marked masks from other countries that are not providing the sufficient protection that a U.S.-standard N95 mask would provide them."
"I’ll never forget the emails I received from Mike Bowen,” who runs Prestige Ameritech, the top surgical mask supplier in the country, Bright said, “indicating that our mask supply, our N-95 respirator supply was completely decimated. And he said, ‘We’re in deep shit. The world is.'"
The PPE shortage is further exacerbated by corporate hospital supply contracts that prevent healthcare providers from looking elsewhere for their supplies.
The national shortage on testing remains as well. According to Ashish Jha, director of the Harvard Global Health Institute, we are testing at less than half the capacity needed to safely and fully reopen states.
"It is not nearly enough, certainly not enough to open up safely and remain open," Jha said. At a minimum, Jha says the U.S. needs to be testing twice as many people — 7 million per week. That means the country is going to need more swabs, more testing kits, and more testing machines to run them. Four months into the pandemic, Jha says, the nation still isn't ready.
So when it comes to Step 2 of the plan to return to normal and defeat COVID-19 in a meaningful way, we need to fortify our defenses. This means:
1 - Making sure areas have enough hospital beds and trained hospital staff to treat the expected rise in cases.
In 2018 it was projected that the US would soon be short over 2 million frontline health professionals under normal circumstances. The current pandemic has only intensified this shortage of critical health professionals.
2 - Making sure those frontline workers have enough quality PPE to protect themselves as they care for COVID-19 patients.
Nearly 600 healthcare workers have already passed away from COVID-19, not to mention the number of those professionals who have become infected with it and are experiencing emotional issues from their experiences with the disease. As of May 1, 2020 over 90,000 healthcare workers had already been infected with COVID-19.
3 - Make sure we have enough tests, test kits, and machines to process those tests so we can effectively track and attack outbreaks as soon as they pop up.
4 - Make sure we have enough manpower to properly contact trace each outbreak to cut off super-spreaders and community spread of COVID-19 as best as possible. For example Texas has been aggressive in keeping its state open during the pandemic yet by their own estimates they are nearly 1,000 people short for their COVID-19 contact tracing efforts.
So as we try to reopen the US and return to normal we need to fortify these defenses or we will fail to prevail in this fight. To better understand what we're up against, take note that just this week alone 22 states have reported their COVID-19 case numbers are on the rise.
There's an old saying that defense wins championships. Right now, our defense has glaring holes in it and without fortifying those holes (hospital capacity, staff, PPE, testing and tracing) we are bound to have the score run-up on us.
Over the past two weeks massive protests have broken out across the world. Before that, we saw mass gatherings as cabin fever led to huge Memorial Day celebrations.
It goes without saying that it is more likely than not that we will see significant spikes in COVID-19 across the US over the next 2-3 weeks as a result of these protests and summer celebrations. As states reopen there's a feeling that the worst is behind us. Though I hope and pray this is true, history and data suggest there's more to this COVID-19 pandemic yet to come.
In September of 1918 there was a large parade to celebrate our soldiers who were fighting in World War I. The parade was also a means of raising funds to support the war effort. That parade unfortunately took place amidst the global Spanish Flu pandemic.
Within 72 hours of the parade, every bed in Philadelphia's 31 hospitals was filled. Within a few weeks of the parade, some 2,600 people in Philly had died.
History tells us we need to be careful as it is reasonable to forecast spikes in COVID-19 to arise from the recent mass gatherings across the country.
If we can calm the anxiety and fortify our defenses we will be better prepared to handle the impending jumps in case numbers as we move forward.
The final step of the plan is to attack. Attack COVID in a way that eliminates it, or at the least vastly diminishes its impact rendering it a minor obstacle rather than a national crisis.
There are many different approaches to tackling COVID-19 just as there are different constraints.
Brazil, for example, has chosen to do virtually nothing and let COVID run rampant through its population in hopes herd immunity will eventually kick in. This has not worked out well.
Sweden has chosen to ban groups larger than 50, but not shutdown its country. The result has been 10 times the fatalities of its neighbors with no measurable economic benefit. In fact Sweden shows GDP contraction between 6% and 10% - similar to their neighbors who did impose lock-down policies.
While the European Commission has forecast a Swedish contraction of 6.1 percent (compared to -6.5 percent for Germany and -7.7 percent for the eurozone), the outlook presented by the Swedish central bank is even more dire -- it anticipates a GDP decline of up to 10 percent. For context, the US experienced 4.8% contraction in Q1.
Then there's New Zealand that has managed to virtually eradicate COVID-19 from its population, without the use of any secret therapeutics or vaccines that have been withheld from the rest of the world.
New Zealand has no active coronavirus cases and no new cases, officials said on Monday, declaring that life could return to a form of pre-pandemic normal. Since the pandemic began, the country has reported 1,504 cases and 22 deaths nationally, and has been widely praised for its stringent approach to combating the virus.
So how do we effectively attack COVID-19 and return to normal?
In the absence of any medicinal interventions (therapeutics or vaccines) to reduce or eliminate COVID-19, we must isolate, contain, and track positive cases. That comes down to testing, tracing, and quarantining cases until we can stop the spread. That requires a large deployment of active testing and tracing squads armed with an abundance of accurate tests and PPE.
Unfortunately the US is still far behind on testing, tracing, PPE, and public health personnel.
Separately, there needs to be a serious commitment to the coordinated development of therapeutics and vaccines. Unfortunately this process can take longer than 18 months to develop and deploy assuming suitable candidates are found.
So what does a real attack plan look like?
1 - Test as many people as you can for active COVID-19 infection as well as for antibodies.
2 - Isolate, treat, and contact trace everyone that tests positive. Ensure there is enough PPE, hospital capacity, and healthy staff to safely treat each active infection case, not to mention enough testing and staff for diligent contact tracing.
3 - Anyone that has not tested negative for active virus or positive for antibodies must take all possible precautions (e.g. masks, social distancing, etc.) to ensure a reduction in the rate of spreading.
According to the WHO, masks can reduce COVID-19 spread by 85%.
4 - Actively monitor via testing and tracing all individuals entering and exiting the US to ensure new strains or super spreaders are not introduced into the US whilst we try to stamp out the infection from within.
If we can take these steps we can achieve a New Zealand like result of completely stamping out COVID-19.
If / when we're able to develop effective therapeutics and / or vaccines, the plan to attack COVID-19 will also include the deployment of a vaccine initiative similar to our current flu shot program as well as ensuring that every hospital has ample supply of therapeutics. Ultimately, home testing and home medicinal remedies will be the goal in taking the fight to COVID-19 before it spreads beyond the home.
Absent a commitment to take the fight to COVID-19 we may be waiting more than a year before life can return to "normal" based on a survey of 511 epidemiologists.
If we implement force majeure economic policies we can calm the economic anxiety that's causing a premature opening of the economy.
If we can ramp up supplies of medical staff, testing, ppe, and contact tracing teams we can safely reopen the economy without overwhelming the healthcare system.
If we can effectively test and trace outbreaks of COVID-19 post a reopening the economy we can isolate and eliminate further spread of the virus.
Once medical interventions become viable and deploy-able we can further attack COVID-19 through "flu shot" type programs and widespread use of the therapeutics.
New Zealand should be a model for the world on how swift and sweeping action for a limited period of time, backed by testing tracing science and data can isolate and eliminate the spread of COVID-19 allowing for a prompt return to normal.
Seemingly every sports film franchise ends up with a bunch of rag tag rejects coming together to overcome the unbeatable foe. Most follow a simple pattern: 1) calm the anxiety, 2) fortify the defense, 3) attack.
If we can follow their example, we too may prevail at the end of the day.