"Social Distancing, Lockdowns & Testing: How to Slow the COVID-19 Pandemic"
I've talked about where the COVID-19 coronavirus came from
and how we might prevent such emergences from animals in the future,
but now that it's spreading human-to- human, what can we do about it?
Social distancing. That's what each of us can do.
Locking down cities, closing nonessential businesses,
cancelling gatherings, and encouraging people to shelter-in-place at home
are all old-school public health strategies to break every possible
chain of transmission.
China was condemned for its early response, sanctioning critics and
denying the extent of the crisis, referring to it as "preventable
and controllable," similar to the response of other world leaders.
But China was later lauded for that same authoritarian approach
when it came to successfully enacting extreme quarantine measures.
A top WHO official praised China's efforts as "probably the most ambitious,
and I would say, agile and aggressive disease containment effort in history."
It was, however, too little, too late to contain the disease locally.
By the time authorities banned travel out of Wuhan, more than a third
of the 14 million residents had already left the region,
whether for the Chinese New Year holiday or to flee before the lockdown
of the city went into effect on January 23. One could argue
that had local officials not wasted weeks silencing whistle blowers
and releasing fake reports, the world could have been spared this pandemic.
But the aggressive actions China subsequently did take
may have indeed brought us all some time. Enacting so-called
wartime control measures, China initiated the largest community
containment effort in history, affecting about three-quarters of a billion people.
Borders were closed, cities were sealed off,
and people were confined to their homes,
unlike so-called lockdowns other countries started instituting,
like the U.S. that still allowed people to venture freely outside
as long as they respected a certain personal distance.
In China, citizens were totally restricted with permission cards
that only allowed them to leave their home every second day
for a maximum of 30 minutes for essentials.
The policy was criticized by human rights advocates, but it worked.
The epidemic immediately started decelerating.
Chinese authorities achieved what many public health experts
didn't think was possible: the containment of the spread of a
widely circulating respiratory infection. Within two months, Hubei Province,
ground zero where the disease first emerged, reported its first day
of no new local cases. "I will praise China again and again"
said the Director-General of the World Health Organization,
"because its actions actually help in reducing the spread
of the novel coronavirus to other countries."
"In many ways, China is actually setting a new standard
for outbreak response." Of course, the day Hubei Province recorded
no new cases, the world confirmed its 200,000th case.
Would the rest of the world be willing to enact rules
one global health policy specialist called "astounding, unprecedented,
and medieval"? The command-and-control authority of the Chinese government
allowed them to enforce a resource-intensive containment
strategy that involved costs to trade, travel, and liberty
that many doubted democracies would be able to stomach.
Thankfully, successful strategies in countries such as South Korea
showed that such draconian measures may not be necessary.
All of the nations that were able to get the disease under control quickly
relied on the foundation of testing and tracing.
In other words, identify all cases through mass testing,
and then trace every possible contact each patient had,
to break as many chains of transmission as possible
through isolation and quarantine.
South Korea had a test approved within the first week of February,
and with enough testing was able to bring the disease under control
by the end of the month.
With such expansive, well-organized testing, countries like South Korea
were able to control the epidemic without resorting to locking down its populace.
The World Health Organization took notice. "We have a simple message
to all countries," the Director-General declared, "test, test, test."
The United States did not appear to get the message in time.
By mid-March, South Korea had already tested more than a quarter million
of its citizens, more than 5,000 out of every million,
compared to fewer than a hundred per million in the United States.
Hamstrung by FDA red tape and a series of blunders,
sufficient U.S. testing capacity failed to materialize before
the window on containment closed. It's humbling to realize
that the U.S. and South Korea recorded their first cases
on the same day, yet the ensuing epidemics took very different courses.
Once containment fails, the strategy then shifts to suppression
and mitigation. If you don't know who's infected,
all you can do is try to prevent everyone from coming in contact
with anyone. By April, most Americans were being told
to stay home to try to curb the spread. As Dr. Fauci said
at a press conference, "If it looks like you're over-reacting,
you're probably doing the right thing."
Closing nonessential businesses and encouraging people to stay inside
to limit social contacts are efforts taken in an attempt to flatten
the curve before it flattens us, flatten the epidemic curve. In other words
slow the spread of the illness to more evenly distribute the cases over time.
This would give health systems time to scale up and respond effectively,
not only to treat COVID-19, but to maintain overall care continuity.
During the recent Ebola crisis in West Africa, for example, deaths increased
from other causes as well, due to the saturation of the healthcare system,
as well as the death of healthcare workers.
School closures are more controversial, as they could threaten the availability
of the 29% of healthcare providers in this country who live in households
that would need to care of young children. One model suggested
that school closures might have to reduce COVID-19 cases
by more than 25% to make up for the loss of healthcare workers
in terms of an overall net reduction in COVID-19 mortality.
A 25% drop may be achievable for pandemic influenza,
a disease in which children may play a critical role
in community transmission, but children don't appear
to be the main drivers of the transmission of COVID-19.
Until an effective vaccine is widely available—
likely not until 2021 at the earliest—
population lockdowns can help rob the virus of susceptible hosts.
Once such measures are relaxed, though, the disease could come roaring back.
In the pandemic of 1918, for example, some U.S. cities experienced a second
peak in mortality following the lifting of social-distancing measures.
Check out what happened in St. Louis.
As soon as they detected a doubling of the baseline mortality,
they instituted school closures and a ban on public gatherings,
and you can see how they were successfully able to bend the curve.
So they decided it was time to relax the social distancing, and they got
a big spike in new cases that required a reinstitution of the shut-down measures.
But the important thing is they instituted the social distancing early,
within days of their first case.
Compare that to how Philadelphia reacted. Took them weeks to shut
the city down and they suffered the consequences.
Here's a graph of that double hump death rate in St. Louis, compared
to what they suffered in Philadelphia.
And here's the mass graves they then had to dig in the City of Brotherly Love.
It's better to be six feet apart, than six feet under.
By periodically pumping the brake with flattening-the-curve strategies
like shelter-in-place ordinances to slow community transmission,
the hope is that we can turn the initial tidal wave of cases
into a series of smaller successive waves our healthcare capability
can more safely ride out. If not, more intensive care units
in U.S. hospitals may become overwhelmed
just as they did in Italy,
and doctors will have to make triage decisions as to who lives and who dies.
Triage protocols have already been published.
First in line for ventilators are those who are most likely to survive,
both in the short term and over the subsequent year.
Then the priority goes to children and adults under the age of 50.
Those 50 to 69 are in the next tier, followed by those aged 70 to 84,
and finally, lowest priority is given to patients 85 and older.
If there's a tie, life-saving ventilation may be allocated based
on some form of lottery, like flipping a coin.
In the New England Journal of Medicine, a preeminent group of medical ethics
experts wrote, we believe that removing a patient
from a ventilator or an ICU bed to provide it to others in need
is also justifiable and that patients should be
made aware of this possibility when they're admitted to the hospital,
adding, "the decision to withdraw a scarce resource to save others
is not an act of killing and does not require the patient's consent."
Wow, can you imagine? To relieve the front-line clinicians of the burden,
they suggest the designation of triage officers to make the decisions.
The countries that were able to mobilize the fastest
and have been able to best control COVID-19 were those
who had learned hard lessons from previous outbreaks.
China, Hong Kong, Singapore, and Taiwan bear the memories of SARS.
More recently, South Korea suffered a MERS outbreak in 2015,
triggered by a businessman returning from the Middle East.
The country's test-and-trace infrastructures were therefore in place
and its populations primed to sacrifice for the promise of containment.
If outbreaks involving dozens or even hundreds of deaths can rally countries
to a state of pandemic preparedness, perhaps the thousands or even millions
of deaths from COVID-19 will orient countries of the world
to the mission of pandemic prevention. But first, what can each of us
do individually to ride out the current pandemic?
That's what I'll cover next.