“US governors seeking to relax public health restrictions on the activity of people and businesses are acting prematurely and risk inciting a second, more damaging wave of infections from the coronavirus pandemic, public health experts have warned.” — The Guardian.
“How to proceed? The U.S. urgently needs to restart, but no economy can function if an infectious disease like COVID-19 continues to sicken the workforce and keep customers to a trickle.” — From an Article in Time compiling expert recommendations on how to restart the U.S. economy in the midst of a mass COVID-19 outbreak.
“Even in the hardest-hit places [in the U.S.], fewer than 1 in 10 people have been infected. So not only could COVID-19 come roaring back, but it could get five times or close to 10 times worse than it is now. The only way forward is to suppress cases and clusters of cases rapidly.” — Dr. Tom Frieden, former director of the U.S. Centers for Disease Control and Prevention (CDC).
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Let’s acknowledge one simple fact. Staying at home to fight a pandemic and to save hundreds of thousands to millions of lives is in itself painful. It can be hard for many reasons. It’s necessary. But, historically, it has been fraught with social difficulty. So as we resolve ourselves not to waver, we should not disparage how difficult the task is.
It comes with economic sacrifice. Preventing loss that would have been even worse if a deadly illness broke out more fully, amplified, and overwhelmed both society-based and healthcare-related systems. But it is sacrifice nonetheless.
It results in social isolation that many have difficulty tolerating. It can be stuffy, stultifying, even claustrophobic. Many of us rely on our contacts with our fellow human beings to maintain emotionally healthy lives. Stay at home thus costs us in less quantitative but very palpable ways for this reason.
In a larger sense it grinds down the body of the human world. It puts civilization into a self-induced collapse into coma. For these reasons and others — it is hard. It requires an effort of collective will to maintain. And it can become tempting to fall prey to messages of false confidence during times of intense social distancing and isolation aimed at saving lives.
Social Distancing — a Sometimes-Necessary Improvement on a Response to Deadly Illnesses that Goes Back Centuries
Historically, though effective, such isolation to prevent death from illness has been difficult to maintain, tricky to time, and vulnerable to resurgent loss of life resulting from the erosion of societal will to maintain isolation for a period long enough to keep deadly illnesses under control. In the mid-to-late 20th Century, as vaccines, antibiotics, and other pharmaceutical treatments became more effective at controlling illness, reduction of illness-resulting contacts became mostly a secondary tool in preventing loss of life. But with the emergence of novel illnesses like HIV, Ebola, and SARS, various forms of isolation and infection prevention through reducing harmful contacts returned. And to prevent loss of life on a far greater scale, social distancing itself has re-emerged during the time of COVID-19 (SARS-CoV-2).
Seattle police wearing masks during the 1918 flu pandemic. Those who didn’t wear masks at the time were called ‘mask slackers.’ In addition to wearing masks, many cities conducted lockdowns in an attempt to prevent illness spread. Early relaxation of lockdowns at the time often resulted in surging rates of infection. Image source: Seattle Police, 1918.
When was the last time society really isolated itself in way similar to the extent we see today during COVID-19? We have to go back to the various quarantine and lock-down strategies deployed during the 1918-1919 flu pandemic a century ago. Back then, events were similar. Masks became widespread. The illness presented a high virulence and risk of loss of life. Cities enacted lockdown proceedures. Some of them opened too soon without other effective disease interventions only to see the deadly illness re-surge in subsequent waves of infection.
But isolation and quarantine itself has roots that reach back much further. All the way to the days of the Black Plague in Italy during the 14th Century. Even then, health ministers had learned that this disease was coming to Venice on ships (specifically from a disease reservoir in infected rats and fleas, but they didn’t know that at the time). They imposed a 40 day wait period or quarantine — derived from the Italian word quaranta for the number 40 — for ships coming to their port in order to contain the spread of the illness.
Other isolation measures were established due to suspicions that the disease was carried from person to person on a ‘pestilential air.’ Captains from ships with plague were spoken to through a window to reduce contact. Infected persons were sent to a quarantine island. All measures enacted to protect the larger population of Venice.
Plague is more specifically transmitted by flea bites, body fluid contact or the consumption of infected animal tissue in the case of bubonic plague, and through infected droplets spread by cough in the case of pnemonic plague. Still, the archaic form of social distancing in Italy was useful in containing and lessening disease outbreaks in the absence of effective pharmaceutical interventions in the form of vaccinations or treatments. It later became widespread across Europe and the world.
These responses come with a cost. They are disruptive. They force people into states of detainment — voluntary or otherwise. Movements are restricted. During quarantines, we lose contacts with our fellows. According to an article on The Science of Social Distancing published on The American Society for Microbiology website:
An organized community response to infection is most critical in the absence of pharmaceutical treatments and cures, but varying levels of political, ethical and socioeconomic controversy have long accompanied these practices.
As difficult as it can be, absent other measures to prevent illness spread, to cure lethal and virulent illness, or to substantially reduce their harmful impact, social distancing, isolation, and quarantine can become necessary to save lives.
How Social Distancing Measures Have Reduced Loss of Life — Reduced Spread, Amplification Prevented, Hospital Supports Preserved
Social distancing works on a number of levels. The first is that it reduces infections by preventing the contacts needed for an illness to spread. Reduced infection rate in a virulent illness like COVID-19 also generally reduces death. It’s basic math that if an illness that has an average case fatality rate of 3.4 percent, as indicated by WHO, is limited to say 100,000 cases where they would otherwise be 1 million, then the total number of deaths is reduced by more than 30,000. For the U.S., the observed case fatality rate is unfortunately much higher than this WHO stated average — on April 30 at around 5.78 percent. This might be due to the fact that the WHO estimate for confirmed case fatality is low, or it might be due to the fact that the U.S. is detecting more life threatening cases, or it may be due to the fact that in places like New York City, the disease has been given space to amplify, to become more deadly. Likely, the presently higher U.S. confirmed case fatality rate is due to some combination of these factors and related considerations. But it is also worth noting that the U.S. case fatality rate is still below a present global average of around 7.1 percent and China’s case fatality rate of around 6 percent (April 30, 2020 figures).
As a second factor, social distancing reduces the ability of an illness like COVID-19 to become more deadly through pure density of infectious particles alone. For if such an illness spreads enough, its deadliness can amplify. What this means is that so many people become ill that infectious material becomes very common in the local environment. This produces generally larger doses of disease when people become exposed. It can produce both multiple lower level exposures that result in a higher infectious dose load over time and the increased potential for much larger single infectious dose loads during encounters with the infectious agent. And larger doses of harmful agents are often more lethal. With COVID-19 there is evidence that this is the case. A recent New York Times piece written by Dr. Rabinowtz and Dr. Bartman noted — “As with any other poison, viruses are usually deadlier in larger amounts.”
The third way social distancing works to reduce lethality in a modern society is by protecting life-saving hospital support. In the instance of COVID-19, ICU cases presently (April 30, 2020) show about a 50 percent mortality. But without ICU care made available, almost all those people needing that support would perish. In other words, people are put on breathing machines because there is a period of time in which the illness removes their ability to breathe on their own — requiring advanced life support. Remove that advanced level of care for many because the need overwhelms availability and the result is that the death rate from the illness again jumps higher.
Hundreds of Thousands Saved
As a result, present social distancing measures in the U.S. and around the world have together reduced loss of life by tens to hundreds of thousands or more. In the U.S. alone, a terrible early national response by the Trump Administration to COVID-19 resulted in widespread weaknesses in infectious disease defense enabling widespread outbreaks, at least some viral amplification, and a pathway that according to CDC would have resulted in between 1.5 and 2.2 million deaths through August without social distancing and stay at home policies. Actions primarily taken by governors across the U.S. in response to rising outbreaks, great risk of loss of life, and related public fear. Now, after this wave of aggressive social distancing, we have the potential to reasonably limit deaths to around 90,000 to 240,000 over the same timeframe (through August 2020). If we manage things responsibly and we are lucky. For the month of April alone, deaths have likely been reduced from a potential of around 150,000 to 350,000 to the present range of around 56,000 to 90,000 when excess deaths likely caused by COVID-19 are included (we won’t know fully for a while due to the up to a two month lag in death certificate completion). This is still a terrible toll. But what we can say is that it would have been much worse if we hadn’t acted.
(Governor Whitmer of a Michigan slammed by COVID-19 cases extended her stay at home order until mid-May last week. This week, armed protesters bringing with them the threat of political violence pushed to force Michigan to re-open early, threatening public health.)
For a certainty, there are a number of the irrational, harmful, and downright terrorist-like armed ‘protests’ coming from the Trump-backing right-wing echo-chamber at present holding ‘make America sicker again’ rallies. Saying just the opposite — that social distancing didn’t work. That it wasn’t needed. That herd immunity alone would have created the reduction in death rates that we have seen because we acted (see experts blast right wing supported herd immunity theory). To, as with climate change denial, generate anti-factually premised arguments that if listened to create false perceptions, false confidence and that risk degrading the effectiveness of action supported by medical professionals and disease fighting experts. Now, these same voices threaten to erode rationality and turn us away from the implementation of life-saving methods as we look toward reopening in a responsible, measured fashion. One more likely to actually help the economy that, itself, relies on health and public confidence in health to function.
Reopening Responsibly Without Proven Pharmaceutical Interventions — Testing, Tracing, Isolating
Fortunately, for modern societies, absent proven effective vaccines or treatments, we still have methods at our disposal for reducing disease outbreaks and limiting spread outside of and in conjunction with social distancing. I touched on these methods in the earlier chapters about South Korea’s effective early COVID-19 containment operation and in the chapter on COVID-19 testing in the United States.
As we look to start reopening, testing, contacts tracing and isolation again, according to disease experts, becomes necessary to ensure the safety of populations. CDC had identified this need as early as mid April stating:
The director for the Centers for Disease Control and Prevention said Monday [April 13] that in order for the country to reopen, swift testing for people who have the virus and for people who might be immune to the virus will need to be available.
However, we are still seeing notable limits in the number of available high-accuracy test kits relative to the number of infections. Present test rates of around 220,000 per day, while numerically high, is still likely not adequate given that the U.S. population is about 330 million (a ten to one negative to positive result is recommended by experts as a benchmark, the U.S. is at 6 to 1 at present suggesting a need to almost double the daily testing rate), that the viral load is a high enough fraction of the present population to represent a serious threat of much larger outbreaks if left unchecked, that the virus is so highly transmissible, and that people possessing antibodies have at best an uncertain immunity at present.
To effectively manage present levels of infection, U.S. testing capacity needs to about double. However, if early or slipshod reopening results in expanded cases, the ability for the U.S. to test, trace, and isolate will again fall behind. Image source: Our World in Data.
As a result, COVID-19 presents a number of challenges for governors wishing to reopen states. The first is that the mentioned viral load in the U.S. now is quite high. We have more than a million confirmed cases as of April 30. We are looking at around 860,000 active cases at present. Dividing the active cases by the existing population shows that about 1 in 400 people have been detected with illness infection in the United States. In addition, COVID-19 is known to produce asymptomatic infections. These asymptomatic cases are still most often in addition to the detected fraction because the continued lower availability of test kits in the U.S. means that most tests are still given to people with symptoms. Asymptomatic cases are also suspected of being transmissible carriers of COVID-19. And the asymptomatic fraction for this illness, based on recent studies, may be rather large, comparable to seasonal flu (which ranges from 12 to 85 percent in virological and serological studies but is typically cited at 20 to 50 percent).
Such a large viral load in the general populace, uncertain levels of infected immunity with a potential for reinfection, and evidence of at least a decent-sized asymptomatic fraction presents a quandry for health officials looking to safely reopen states and to protect the general population. That said, and given what we know, we can work to effectively deploy resources to protect the public as states look to start re-opening.
Reopening Under CDC Guidance and Aggressively Taking on the Virus — Setting Public Safety as the Top Priority
The first key step, according to health experts, is to not re-open while viral cases and hospital cases are still expanding. Reopening should occur according to CDC guidelines following a two week reduction in cases. Since cases are still at plateau or are still expanding in many states, this would suggest that rational re-opening timeframes for most regions run from mid-May to mid-June. However, this range is provisional based on expected viral drop-off rates. And COVID-19 has tended to linger for longer than expected in some regions. Opening earlier risks larger outbreaks. And the history of opening while cases are still rising without other effective interventions is full of stark examples (see lack of quarantines allowed 1918 flu to spread and grow).
The second step is to, according to CDC, widely deploy available testing. Ideally, this testing will be broad enough to effectively detect, trace and isolate a majority of the cases. CDC guidance appears to assume it will be. However, given that the U.S. is not at the recommended 10 to 1 negative to positive test threshold, there is evidence that test shortages are still an issue. Therefore, like Maryland Governor Larry Hogan directed yesterday, testing resources may need to be deployed in a more targeted manner. For example, Hogan indicated that highest risk case clusters are occurring in meat packing facilities and in nursing homes.
As an example, Hogan’s action of aggressively deploying available testing, contacts tracing and isolation for those hot spots produces a greater opportunity to reduce risk of expanding infection and loss of life. Also Maryland’s example of setting up drive-through testing centers when test kits are available for people with symptoms, along lines similar to those of the South Korea model, provides a secondary, targeted containment infrastructure. It is worth noting that Hogan is departing from his earlier tact of adhering strongly to expert advise on reopening timelines. Hogan presently plans to reopen as soon as hospitalized cases plateau for two weeks — rather than according to the two week case reduction recommendation by CDC. This particular facet does increase risk to Marylanders.
In the absence of available test kits, temperature screening in workplace and other environments is an available option to increase infection contaiment. This is a broader brush approach. And it does not detact the assymptomatic fraction of cases. But it does help to contain the most highly infectious instances. CDC provides a useful set of guidelines for conducting such screening here.
In addition, provision of protective barriers, increased ventilation, and face coverings for persons in any re-opened public work environments according to CDC guidance would help to limit contacts and disease spread. People in workplaces, social gatherings, using mass transportation, and in many aspects of life and work would help to prevent loss of life during any reopening scenario by following such CDC guidance as well.
Other Considerations — Start and Stop, Effective Communication, Doing Real Work to Build Trust
Finally, considering the continuing great risk to public health, reopening may need to start and stop. Meaning that if infections increase, reopened sectors may need to shut down again to limit disease spread. These response shut-downs could be total or staggered — escalating and de-escalating based on observed changes in outbreaks.
Overall, the idea is to respond to the virus in a smart, flexible manner that both protects the public and generates the real confidence needed to get the economy up and running. Listening to infectious disease expects, healthcare leaders, CDC, local leaders and the general public will be crucial in this regard. On the one end, specific knowledge and concerns provided by health and disease experts saves lives, and on the other end, local leaders and the public will give an understanding as to whether communities and individuals feel they have been protected during any re-opening. This communication with the public both gauges public confidence, which is necessary in any reopening, and increases state leadership’s responsibility to protect lives.
Daily U.S. COVID-19 deaths are on a long plateau. Whether they go up or down depends in large part on if reopening is rushed and botched, or cautious and effective. Image source: Worldometers.
Potentially helpful infectious disease treatments and new pharmaceutical interventions may aid in any reopening strategy by reducing stress on hospitals, potentially reducing loss of life, and helping to increase public confidence. But at this time it is important to consider that none of the present potential interventions, as yet, is a silver bullet. So the effectiveness of any new treatments should not be over-stated in a way that undermines trust.
We are entering a tricky time fraught with danger. But if we are wise, cautious, and fortunate, we may begin to climb out of this terrible pandemic. Hasty, reactionary responses that ignore the advice of health experts, however, carry with them a high risk of worsened tragedy and even more terrible loss of life than we have already experienced.
Up Next: A Possible Vaccine, But When?
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