To my Patients and Friends,
Hi there, everyone... I've dusted off the crystal ball again today. Read on for some interesting updates.
Summer break?
Researchers at The National Academy of Sciences, Engineering, and Medicine have speculated that COVID-19 may not exhibit a typical seasonal pattern as with influenza, and that COVID-19 won't disappear during the warmer months. It is notable that neither of the related coronaviruses that cause severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS)- nor the flu strains associated with previous pandemics- have demonstrated seasonal patterns. So, although a seasonal pattern has been predicted by leading experts like Dr. Anthony Fauci, it's increasingly likely that COVID-19 won't be going away any time soon and that some form of social distancing will be necessary even through the summer. It's also reasonable to assume that our economy won't be opening with the "big bang” any time soon, as some news figures might be encouraging us to expect. Stay tuned... more to come on this for sure.
So is there an escape route?
This interesting article written by Ezra Klein reviews some of the major existing proposals that may enable us to gradually move away from sole reliance on strict physical distancing as a means of curbing the spread of COVID-19 and to begin the process of getting our lives and our economy up and running. They may sound extreme, and I wish there were simpler, more savory options, but they're based on evidence, logic and the experiences of other countries. And I do believe that something along these lines will probably be necessary in order for us to get ourselves back on track.
No matter the plan, some basic assumptions can be made: (1) none of these plans are perfect, (2) it will be a slow, deliberate and onerous process, (3) a lot will depend on how quickly we can develop effective treatments and a viable vaccine program, and (4) there will be no normal for the foreseeable future.
All of the plans call for a comprehensive and potentially intrusive surveillance program and/or a comprehensive and potentially intrusive testing program. Additionally, all of the proposals would face political, organizational and sociological challenges. They presume unprecedented levels of coordination which would need to be centrally driven. This may seem inconceivable, given our current leadership. And some suggest that individual states may need to fluidly transition into and out of lockdown staus as necessary based on regional epidemiologic trends. Although these proposals may seem onerous, without a robust plan along these lines, it's difficult to imagine that we can begin returning to “normal” life over the course of the year ahead. And it's doubtful that any comprehensive proposal can be implemented in the absence of very consistent and thoughtful coordination at the highest levels.
Three of the four main proposals are similar, in that they define a national lockdown period during which stringent social distancing measures would be implemented in order to flatten the curve, while resources are simultaneously put into place in order to increase COVID-19 testing and healthcare service capacities (i.e., to raise the line). They also imagine a follow up phase, during which social-distancing is systematically relaxed (but not ended) while mass surveillance and testing systems are implemented. Although the information technology (IT)-based surveillance designs discussed in these plans could present some privacy concerns (and to many may seem dystopian), they would be critical to the success of any of these proposals. Some suggest downloading contact tracing applications onto cell phones or use of QR codes or other smartphone applications for movement tracking; alternatively, GPS tracking could be used to enforce quarantine on those who test positive with the disease, as is being done in Taiwan. In fact, Apple and Google have already teamed up to develop technology that will alert those who may have come into contact with a COVID-19-afflicted individual.
A critical underpinning of all plans is that, in order for us to transition to a new normal, we will need effective treatments and, most importantly, a vaccine.
The proposals in a nutshell:
- A plan from Harvard University’s Edmond J. Safra Center for Ethics proposes a 3-month national lockdown. Thereafter, a disease-tracking protocol involving millions of coronavirus tests per day would be instituted alongside a robust digital surveillance architecture. The plan also proposes a mandated national service corps that would employ those who are deemed to be immune to the coronavirus based on blood testing to perform vital services from which others are restricted due to lack of immunity. This plan proposes trillions of dollars in up-front spending on an unprecedented pandemic IT surveillance system, massive testing capabilities and vastly improved vaccine production processes. Although this would lead to some economic loss along the way, the plan assumes that we will ultimately benefit from downstream economic stimulus and a vastly improved public health system.
- The more left-leaning Center for American Progress has produced a model- inspired by South Korea's approach- which emphasizes heavy use of IT- for instance by downloading contact tracing applications onto cell phones. This plan proposes that, after a 45-day national lockdown, when someone tests positive for the virus, anyone who is determined to have been in contact with that infected individual based on cell phone data could be advised to quarantine or self-isolate. The plan lays out specific measures designed to ensure confidentiality and personal privacy. Some sobering travel restrictions are also discussed in this model- for instance, for a period of 18 months, until herd immunity has been established, airline travelers would need to download a contact-tracing app, confirm no close proximity to a positive case, and pass a fever check or show documentation of immunity based on a blood test. TSA would need to adjust their screening procedures to ensure physical distancing and limit airport terminal access to ticketed passengers only. Subways, buses and transit stations would need to limit the number of passengers to 50% of capacity. Buses would need barriers between passengers and drivers.
- Nobel Prize-winning economist Paul Romer and his colleagues emphasize massive testing- up to 22 million tests per day- over information technology. In this model, the entire population is tested repeatedly every 14 days, and it uses test result analyses as an alternative to digital contact tracing. Romer shows that even with a high false-negative rate, frequent retesting is sufficient to contain the virus, thus enabling a new normal to come to fruition more quickly. Of the plans discussed here, this one may most likely enable a meaningful and accelerated economic recovery. Although the model is sensible, it seems unrealistic to expect that we can arrive at that testing capacity. An alternative approach might be to use this plan for testing certain essential professionals- health workers, city workers, public safety workers, transit workers, food service workers, etc.
- A proposal from the right-leaning American Enterprise Institute may be the closest thing to a middle path. It suggests that, after a 14-day national lockdown period during which COVID-19 cases decrease, with a concomitant scaling up of our healthcare infrastructure, we can begin to reopen businesses while minimizing spread of the virus with more contact tracing and with ongoing modified forms of social distancing. It emphasizes more testing, but nothing approaching the Romer model reviewed above. It also involves more contact tracing, but it doesn’t necessarily envision an intrusive IT-driven model. It describes an ongoing back-and-forth between extreme lockdown measures and lighter forms of social distancing until a vaccine is released. But this may be a tall order: it's hard to imagine that leaders who have finally been able to reopen parts of their economies would be willing to resume lockdown status if, for instance, ICUs begin to refill.
In discussing the potential benefits and pitfalls of these well-conceived proposals, Klein notes that his intent "isn’t to criticize these plans when (he has) nothing better to offer. Indeed, (his) point isn’t to criticize them at all. It’s simply to note that these aren’t plans for returning to anything even approaching normal. They either envision life under a surveillance and testing state of dystopian (but perhaps necessary!) proportions, or they envision a long period of economic and public health pain, as we wrestle the disease down only to see it roar back, as seems to be happening in Singapore."
You can also listen here to a more detailed discussion of the above.
Food safety update
This useful piece from the Journal of the American Medical Association (JAMA) is a practical guide that can be used to help safely navigate the world of food in the age of COVID-19
The latest Q&A with Dr Anthony Fauci
He's still one of the best sources for evidence-based guidance and information... if interested, listen here.
On the shoulders of giants
Some of you may recall a scene from the movie The Aviator in which Leonardo Dicaprio portrays Howard Hughes navigating a challenging moment... it resonates. Watch it here.
That's all for today. I hope you all enjoy your families as you celebrate Easter and Passover. Please stay well, be kind, practice physical distancing and continue to look out for each other.
Larry Leibowitz, MD
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