These are days that test every leader — local, state and national. They are each being asked to make huge life and death decisions, while driving through a fog, with imperfect information, and everyone in the back seat shouting at them. My heart goes out to them all. I know they mean well. But as so many of our businesses shut down and millions begin to be laid off, some experts are beginning to ask: “Wait a minute! What the hell are we doing to ourselves? To our economy? To our next generation? Is this cure — even for a short while — worse than the disease?”
I share these questions. Our leaders are not flying completely blind: They are working off the advice of serious epidemiologists and public health experts. Yet we still need to be careful about “group think,’’ which is a natural but dangerous reaction when responding to a national and global crisis. We’re making decisions that affect the whole country and our entire economy — therefore, small errors in navigation could have huge consequences.
Of course, because this virus is potentially affecting so many Americans at once, we need to provide more hospital beds, treatment equipment for those who will need it and protective gear like N95 masks for the doctors and nurses caring for virus-infected patients. That is urgent! And we need to immediately rectify the colossal failure to supply rapid, widespread testing. That is urgent!
But we also need to be asking ourselves — just as urgently — can we more surgically minimize the threat of this virus to those most vulnerable while we maximize the chances for as many Americans as possible to safely go back to work as soon as possible. One expert I talk to below believes that could happen in as early as a few weeks — if we pause for a moment and think afresh about the coronavirus challenge.
Indeed, if my inbox is any indication, a thoughtful backlash is brewing to the strategy the country has stumbled into. And stumbling is what inevitably happens when you have a president who goes from treating the coronavirus as a hoax to a war in the space of two days. A lot of health experts want to find a better balance to the medical, economic and moral issues now tugging at us all at once.
Dr. John P.A. Ioannidis, an epidemiologist and co-director of Stanford’s Meta-Research Innovation Center, pointed out in a March 17 essay on statnews.com, that we still do not have a firm grasp of the populationwide fatality rate of coronavirus. A look at some of the best available evidence today, though, indicates it may be 1% and could even be lower.
“If that is the true rate,’’ Ioannidis wrote, “locking down the world with potentially tremendous social and financial consequences may be totally irrational. It’s like an elephant being attacked by a house cat. Frustrated and trying to avoid the cat, the elephant accidentally jumps off a cliff and dies.”
Dr. Steven Woolf, director emeritus of the Center on Society and Health at Virginia Commonwealth University, shared with me some thoughts he was hammering into an essay: “Society’s response to COVID-19, such as closing businesses and locking down communities, may be necessary to curb community spread but could harm health in other ways, costing lives. Imagine a patient with chest pain or a developing stroke, where speed is essential to save lives, hesitating to call 911 for fear of catching the coronavirus. Or a cancer patient having to delay chemotherapy because the facility is closed. Or a patient with advanced emphysema who dies for lack of a facility with a ventilator.’’
And imagine the stress and mental illness that will come — already has come — from our shutting down our economy, triggering massive layoffs.
“Income is one of the stronger predictors of health outcomes — and of how long we live,” Woolf said. “Lost wages and job layoffs are leaving many workers without health insurance and forcing many families to forego health care and medications to pay for food, housing and other basic needs. People of color and the poor, who have suffered for generations with higher death rates, will be hurt the most and probably helped the least. They are the housekeepers in the closed hotels and the families without options when public transit closes. Low-income workers who manage to save the money for groceries and reach the store may find empty shelves, left behind by panic shoppers with the resources for hoarding.”
Is there another way?
One of the best ideas I have come across was offered by Dr. David L. Katz, founding director of Yale University’s CDC-funded Yale-Griffin Prevention Research Center and an expert in public health and preventive medicine.
Katz wrote an Op-Ed in The Times on Friday that caught my eye. He argued that we have three goals right now: saving as many lives as we can, making sure that our medical system does not get overwhelmed — but also making sure that in the process of achieving the first two goals we don’t destroy our economy, and as a result of that, even more lives.
For all these reasons, he argued, we need to pivot from the “horizontal interdiction” strategy we’re now deploying — restricting the movement and commerce of the entire population, without consideration of varying risks for severe infection — to a more “surgical’’ or “vertical interdiction” strategy.
A surgical-vertical approach would focus on protecting and sequestering those among us most likely to be killed or suffer long-term damage by exposure to coronavirus infection — that is, the elderly, people with chronic diseases and the immunologically compromised — while basically treating the rest of society the way we have always dealt with familiar threats like the flu. That means we would tell them to be respectful of others when coughing or sneezing, wash their hands regularly and if they feel sick to stay home and get over it — or to seek medical attention if they are not recuperating as expected.
Because, as with the flu, the vast majority will get over it in days, a small number will require hospitalization and a very small percentage of the most vulnerable will, tragically, die. (That said, coronavirus is more dangerous than the typical flu we are familiar with.) As Katz argued, governors and mayors, by choosing the horizontal approach of basically sending everyone home for an unspecified period, might have actually increased the dangers of infection for those most vulnerable.
“As we lay off workers, and colleges close their dorms and send all their students home,” Katz noted, “young people of indeterminate infectious status are being sent home to huddle with their families nationwide. And because we lack widespread testing, they may be carrying the virus and transmitting it to their 50-something parents, and 70- or 80-something grandparents.”
“OK,” I said, calling Katz by phone at his home in Connecticut after reading his article, “but we are where we are now. Most states and cities have basically committed to some period of horizontal social distancing and sheltering in place. So, can we make lemonade out of this lemon — and not destroy our economy?”
I don’t see why not, he answered. “Now that we have shut down almost everything, we still have the option of pivoting to a more targeted approach. We may even be able to leverage the current effort at horizontal, population-wide, interdiction to our advantage as we pivot to vertical, risk-based, interdiction.”
How? “Use a two-week isolation strategy,’’ Katz answered. Tell everyone to basically stay home for two weeks, rather than indefinitely. (This includes all the reckless college students packing the beaches of Florida.) If you are infected with the coronavirus it will usually present within a two-week incubation period.
“Those who have symptomatic infection should then self-isolate — with or without testing, which is exactly what we do with the flu,” Katz said. “Those who don’t, if in the low-risk population, should be allowed to return to work or school, after the two weeks end.”
Effectively, we’d ‘reboot’ our society in two or perhaps more weeks from now. “The rejuvenating effect on spirits, and the economy, of knowing where there’s light at the end of this tunnel would be hard to overstate. Risk will not be zero, but the risk of some bad outcome for any of us on any given day is never zero.”
Meanwhile, we should do our best to sequester from any contact with potential carriers the elderly, people with chronic diseases and the immunologically compromised for whom coronavirus is most dangerous. And “we could potentially establish subgroups of health professionals, tested to be negative for coronavirus, to tend preferentially to those at highest risk,” Katz added.
This way, Katz said, “the most vulnerable are carefully shielded until the infection has run its course through the rest of us — and the tiny fraction of those of us at low risk who do develop severe infection nonetheless get expert medical care from a system not overwhelmed. … We are not counting on zero spread after the two weeks; we cannot achieve zero spread under any scenario. We are counting on minimization of severe cases by sheltering the most vulnerable from spread whether by those with, or those without, symptoms.”
That is why we should also use this two-week (or longer, if that is what the CDC decides) transition period to establish through data analytics the best possible criteria for differentiating the especially vulnerable from everyone else. For instance, some younger people have been killed by coronavirus. We need to better understand why. There is some research, Katz says, that suggests many of them, too, had other serious chronic primary medical conditions, but this needs more data and analysis. Who exactly is at high risk must be based on the most current data and updated routinely by the relevant public health authorities.
This is why pushing the federal government to expand testing as broadly and quickly as possible is so important.
Katz has created a rough template for the two-week-plus-sequestration-of-the-most-vulnerable strategy and how to think about coronavirus risk stratification, and different responses, on his website.
Katz’s approach is both sober and hopeful. He is basically arguing that at this stage there is no way of avoiding the fact that many, many Americans are going to get the coronavirus or already have it. That ship has sailed.
“We missed the opportunity for population-wide containment,” he said, “so now we need to be strategic opportunists: Let those who are inevitably going to get the virus, and are highly likely to make an uneventful recovery, get it and get over it, and get back to work and relative normalcy. And, meanwhile, protect the most vulnerable.”
During this time, we would want to set up mobile testing and temperature-check systems — as China and Korea have done — to identify those who may not comply with this 14-day isolation approach, or for any other reason remain or become infected. We would also want carefully to confirm that, once you recover from COVID-19, you are immune from getting it or spreading it again for a period of time. Most experts believe that to be true, said Katz, but there have been some reports of reinfection, and the matter is not settled.
“Confirming that individuals are fully recovered, truly immune, and not capable of transmitting is a crucial element in protecting our loved ones most vulnerable to severe infection,” Katz said.
Once transmission rates are down to near zero, and herd immunity has been established, concluded Katz, we can think about giving the “all-clear’’ to the most vulnerable. This could take months. But Katz’s plan offers the majority of the population the prospect of normalcy in some relatively small number of weeks, rather than indefinite number of months.
And all the while, of course, there should be brisk work on effective treatments and vaccine. These should be deployed — globally — as soon as reasonable.
I am not a medical expert. I’m just a reporter — who is afraid for his own loved ones, for his neighbors and for people everywhere as much as anyone. I share these ideas not because I know they are the magic cure, or have every variable thought through. I share them because I am certain that we need to broaden the debate — I am certain that we need less herd mentality and more herd immunity — as we come to terms our hellish choice:
Either we let many of us get the coronavirus, recover and get back to work — while doing our utmost to protect those most vulnerable from being killed by it. Or, we shut down for months to try to save everyone everywhere from this virus — no matter their risk profile — and kill many people by other means, kill our economy and maybe kill our future.
Thomas L. Friedman | The New York Times
Thomas L. Friedman, a three-time Pulitzer Prize winner, is an Op-Ed columnist for The New York Times.
