Listen: Dr. David Lubarsky
CEO, UC Davis Health and Vice Chancellor talks about his article reviewing the past 6 months of how we have responded to the Covid-19 pandemic.
His article follows.
The virus that causes COVID-19 has infected more than 25 million people globally and left more than 170,000 dead in the U.S. Meanwhile, about 400 million jobs have been lost worldwide, 13 million in the U.S. alone. The pandemic will likely end up costing between $8.1 and $15.8 trillion globally, according to the World Economic Forum.
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Staying at Home for 6 Months: Time to Rethink Our Response?
By Dr. David Labarsky
It’s been six months since California issued its shelter-in-place shutdown order on March 19. During this time, we’ve learned quite a bit about the virus that’s causing the pandemic, and this new knowledge is evolving our thinking about what works and what doesn’t work. We flattened the curve here in Sacramento in those early months – better than nearly everyone else in the nation, but also not like we expected. Now, we have to smartly sort out how we’re going to ride out these next few months before vaccines are approved (hopefully before the end of the year) and distributed equitably and widely.
The virus that causes COVID-19 has infected more than 25 million people globally and left more than 170,000 dead in the U.S. Meanwhile, about 400 million jobs have been lost worldwide, 13 million in the U.S. alone. The pandemic will likely end up costing between $8.1 and $15.8 trillion globally, according to the World Economic Forum.
We now know who the virus impacts most: People in nursing homes and older adults. Nearly half of deaths have been people in group living facilities (such as nursing homes) and 80 percent of deaths have been people age 65 or older – 91% of the deaths have been people aged 55 or older. And it has been reported that residents of nursing homes serving the Medi-Cal population primarily fared more poorly than those nursing homes with more resources, further exacerbating COVID’s deadly impact on underserved communities.
When history books tell the story of the 2020 pandemic, it will start with the sad slew of public failings – the lack of public health investment and failure to prepare for such a pandemic, the uncovering of health care inequity and institutionalized racism, and the outsized pandemic impact on underserved communities. It will undoubtedly also mention the rift in our society caused by the hurtful turn of public health debates into polarizing political statements that hurt us all.
But I refuse to see that as the end, as I firmly believe it may well end as a tale of human adaptability and ingenuity. We will overcome this crisis, but until then, we find ourselves at a critical turning point – what is next? Here are some thoughtful, tactical and empathetic approaches to vanquishing COVID-19:
Rethinking Total Lockdowns
Lockdowns are effective at reducing virus spread by decreasing the number of people circulating and spreading it. But they are an economically costly tool, and politically difficult to keep in place for a long enough time to eradicate the virus risk. We don’t stop driving because upwards of 40,000 people die in car accidents every year. We balance risks and benefits to society and implement common sense rules to limit the carnage – things like traffic lights, and speed limits and airbags. A similar approach can be taken here.
We now know who is most at risk of dying, so clearly these are the people who need to be more fully protected. We can protect our older adults and those in group living facilities. This requires mandated reporting from these facilities of COVID-19 cases and mortalities. It also requires PPE distribution and training of staff for its use, periodic testing of staff and visitors (who are the likely vectors in transmission), and periodic whole facility testing.
We also need to ask ourselves as a society what represents an acceptable level of infection? On one hand, if we’re striving for a “zero” rate of infection, then by definition long-term shutdowns would have to be well-enforced and repeated – at least until an effective treatment or vaccine can be distributed widely. Most countries have rejected this course as unrealistic and have reopened at different speeds – with differing results.
On the other hand, there is Sweden’s approach, which was to head toward herd immunity for its population, while keeping basic human activities open. The idea was to reach a point when enough of the population would become immune, due to prior exposure or an eventual vaccine, so that transmissions would decline and the epidemic would fade away. Most countries abandoned that strategy, as research has clearly shown that in the absence of social distancing (I call it physical distancing), the pandemic only continues to expand. And the toll, in lives, is likely higher than most people would accept.
The rate of spread is determined by three principal factors – adherence to mask wearing, contact/mixing, which is related to both personal behaviors and population density (bars are bad, for example), and how infectious the virus is in spreading from one person to another. We have control over the first two. New discoveries may impact the third factor, so this is not something that is entirely out of our hands, as I’ve heard some fatalists say.
The challenge is that we, in the U.S., have not decided upon our approach. Some states are aiming for containment and near zero new infections, while others are striving for some mitigation and management. We’re in the middle and, as a result, get the worst of both approaches.
Mitigation vs. Suppression
A key factor in an epidemic’s spread is the reproduction number, or“R value.”The R value represents how many people each infected person eventually infects. Mitigation strategies typically strive for an R of just above one, while suppression aims for an R of below one. Full-blown mitigation means accepting a high number of additional deaths to achieve herd immunity, which public leaders and health experts justifiably will not accept.
A quick calculation explains this: With 330 million Americans, about 60 out of 100 need to become infected and then persistently immune to prevent further spread. That’s about 200 million people. The current 3% case fatality rate (~200,000 deaths out of 6 million infected) is not the number. Because of woefully inadequate testing means, we know with fairly good certainty the number pretty much who have died (the numerator), but we donothow many were really infected (the denominator). The current best guess is a 0.5% to a 1% fatality rate. Even if it is at the lower end, 0.5% of 200 million infected equals 1 million dead Americans – and these would not just be older people. (Yes, ageism is a thing, and those who deny the value of life in the elderly should go talk to their grandmother again.)
However, total suppression of COVID-19 is also impractical, because of the economic and job losses it creates. We also don’t live in an authoritarian country like China, which forced total suppression on its citizens with unforeseen consequences. We’re not an island like New Zealand, which has used complete lockdowns, for weeks at time, on a repeated basis. The impact of our own shelter-at-home orders on families, the economy, and mental health are not yet fully understood.
The problem is this: As a country, we’ve never resolved whether we’re following mitigation or suppression strategies.
Mitigation means changing personal behaviors (yes, still wearing a darn mask in public, especially indoors or in any larger gathering, and neither our president nor Fox News helps that), but accepting there will be a number of dead until vaccines or treatments arrive. We have not settled on what constitutes an acceptable toll, so we wring our hands over every death (and CNN’s daily trumpeting of numbers doesn’t help either).
Suppression requires more draconian changes in interacting with others, truly cooperative public behaviors and a large contact tracing workforce. We aren’t investing the required billions in contact tracing, but we are pouring trillions into mitigation of the economic harm, which the lack of contact tracing is causing in the first place. And, we don’t agree how far we must drive transmission down before allowing some loosening.
Waffling back and forth between these two approaches has earned us some of the worst of both strategies. This has created confusion, caused a lack of trust in many public health messengers, increased deaths and economic damage, and in the end, we’ve failed to truly manage virus spread, as we saw this summer in the infections spikes across the country.
An Alternative Approach That Works
We’re clearly going to have to find a balance between these two approaches – and articulate that as our strategy. This alternative approach would focus on reopening as much of the economy as possible, for the highest possible economic benefit, while aggressively following mandated masking policies, hand hygiene, smart testing with rapid results (we are getting there soon), and enforced physical distancing protocols. This will save lives and save the economy. And frankly, this will save lives not only from COVID-19, as depression and anxiety are at all times high in our society.
In Taiwan, they’ve achieved this reset. Taiwan has confirmed 488 COVID-19 cases and just seven deaths in a population of 23.7 million. (That is about two-thirds the population of California, which has seen nearly 15,000 deaths by comparison.)
Testing, as I’ve previously written about, should prioritize those most at risk– the elderly, front-line health care workers, and those with pre-existing health issues or who are in congregate living arrangements such nursing or elder or disabled facilities. It should produce results quickly, so action can be taken before others are infected. Protective isolation can consider risk factors, especially for older adults or those with other high-risk factors. A nationally supported – emotionally and physically –isolation strategy for elderly residents and those with multiple health conditions could have saved many lives with much less economic cost.
Going forward, we know COVID-19 has changed the way we work and the workplace, even after the pandemic has ended. I’ve tasked a group at UC Davis Health to study the nature of remote working as part of our “office of the future” concept. The group will review who needs to be close to patients, which groups can work farther away, and which teams can do their work remotely – even after the current COVID-19 situation concludes. Many companies in America are doing likewise – the end result could be better ways to maximize personal health and safety, while boosting efficiencies in the workplace and keeping the economy running.
One silver lining to all this COVID activity is the impact of the flu season in March was literally halved from previous years. Maybe we can all learn to be healthier moving forward, as a result of our trials here. Maybe we’ll see similar decreases in the coming flu season – which could help save some of the more than 34,000 deaths each year in the U.S. from the flu.
Communities and countries that have more successfully controlled the spread of the virus have focused on two things: understanding what to do and executing that well, and consistently, and without trying to make facts match political positions. We can do much better at analyzing and sharing the evidence collected about COVID-19 now that these shelter-in-place orders are six months behind us.
By calibrating our future approach to protect those especially vulnerable, and better executing our strategies, more people can more fully resume their lives, carefully, of course, with benefits for all in the economy, jobs, and families. Much depends on forging an equitable and balanced path forward. Zero deaths is not the endpoint, and one million deaths is not acceptable. We all know this, and we need to help our leaders forge a centrist path.
This is why we have scienceandcommunity, and once again we see it works best when both work together.