We have a tiger by the tail (barely), now how do we let go??
There’s no time or ability for me to micromanage my medical team when they are 6,000 miles away, out in the remote jungle and far from any cell coverage. They constantly have to make tactical medical and logistic decisions in a dangerous environment with few resources. How do I make sure that they make the right choices? And how does this relate to managing Covid-19?
My job as leader is to ensure that everyone fully understands the mission STRATEGY — the vision for what we want to achieve and what victory should look like. When the vision is clear, the right tactical decisions flow naturally from my end operators and they return safely from the jungle to log yet another successful clinical deployment. The other big part of my role as leader is to share useful information I have received from other sources, to listen when they tell me what they need, and do my best to get it for them as fast as I can.
Local operators need strategic guidance from above, but mostly they need autonomy, information and resources. Different solutions do work better in different local settings — what works in Manhattan might not work in South Central Los Angeles, or in a small rural town in Georgia. It is appropriate that local agencies take the lead implementing effective tactical measures against Covid-19 on their home turf, with any needed support and access to collected information from the Federal government. But what is the overall strategy being shared with local operators so they can aim for the right targets? And what exactly is the victory we are trying to win? Here’s what I see as victory:
- Get through Covid-19 with as little death and suffering as possible by slowing the spread, reducing the number and rate of infections and improving outcomes for infected people
- Protect economies and infrastructure without violating #1 and minimize burdens that fall unequally through direct assistance, consumer and business behavior modification, and support of local and national economies by local and federal agencies
- Come together as as a global civilization and emerge from this stronger as a species, more robust against future viruses like Covid-19 (or worse) that cross all borders
Awash in ideas, possible solutions, knowledge gaps and conflicting messages from different agencies, it’s time to narrow our focus back to the core mission and identify a few key strategies for local policymakers to find tactics to achieve the victory we want.
The First Strategy is implementing and maintaining well-vetted infection control measures at all levels from individual to global, such as social distancing, hand washing and basic hygiene measures, properly used personal protective equipment (masks, eye protection and avoiding face touching either by magic or by a veil as we suggest) and shutdowns/sheltering in place. Oceans of digital ink have been written about these methods so far, so we’ll skip any further exploration of them here, but in case you’re wondering if social distancing is helping, here’s a comparison of Kentucky and Tennessee’s caseload development. Which state do YOU think implemented social distancing and shutdown earlier than the other?
Even a week’s lead seems to be a significant advantage, and this is not unique in this pandemic, or even TO this pandemic. Here’s what a similar difference in the rapidity of response meant in 1918, between Philadelphia and St. Louis — DAYS matter in these kinds of spreading epidemics:
It would seem that in any but a very small country, local initiation of responses works faster and more efficiently. In Germany, one factor that helped significantly was the local autonomy for the implementation of health policies — including factors such as the formidable Gesundheitsamt structure of hundreds of well-organised public health offices across the country that rigorously enforce rules and regulations on hygiene and health care and have the authority to shut down public life. Local action supported from above seems almost always able to be faster than national action, and time is critical in these kinds of epidemics.
The Second Strategy is to implement as widespread effective antibody testing as possible, as fast as possible. We’ve actually tested about 3 million people in America so far — about 10% of our population — but that’s a drop in the bucket for what we need. Swab tests are labor and time intensive and can only tell if someone is actively infected at that time. Accurate rapid antibody tests can take minutes and can even be done by someone at home, and can tell if someone is actively sick or if they were previously infected and now recovered. We know so little about this virus’s behavior, and massive testing kills several birds with one stone:
- Provides invaluable epidemiology data that lets us develop national policies that can be locally tailored based on local testing data
- Allows earlier detection of infected people to prevent them getting dangerously sick without treatment (people feeling mildly unwell can suddenly de-oxygenate while still at home) and to quarantine them to protect others
- Allows ‘Contact Tracing’ and quarantine of exposed people before they can spread it further
- Allows us to track and surveil whether interventions we are trying are working
- Allows us to begin reactivation of sectors of our economy by identifying recovered people who have immunity and can go back to work, or areas with sufficient herd immunity to relax some restrictions
A new antibody test study by the National Institutes of Health is being launched this week to test 10,000 adults in the US who were not known to be infected but who might be found to carry antibodies, indicating prior infection. “This study will give us a clearer picture of the true magnitude of the COVID-19 pandemic in the United States by telling us how many people in different communities have been infected without knowing it, because they had a very mild, undocumented illness or did not access testing while they were sick,” said Anthony S. Fauci, M.D., NIAID director. “These crucial data will help us measure the impact of our public health efforts now and guide our COVID-19 response moving forward.”
Mike Ryan, head of the World Health Organization’s Health Emergencies Programme, agrees that countries with early and aggressive testing are “able to make tactical decisions regarding schools, movements, and are able to move forward without some of the draconian measures.”
You can see in the below graph of South Korea that cases that peaked rapidly and then dropped off drastically — even without closing any restaurants or schools. South Korea has only had 217 Covid-19 deaths, without the strict lockdown measures implemented across the U.S. and in many parts of Europe. Why? Because they immediately rolled out widespread testing and contact tracing to isolate those infected as well as those they’d been in contact with. This is essentially ‘running after and chasing’ the virus but because they started early enough and quickly enough that they caught up with it before Covid-19 got too far out in front.
More than 230 test developers have either submitted or will soon submit requests for FDA emergency authorization of their product. However, right now only one rapid antibody test made by Cellex, is approved by the FDA and the company hopes to ship as many as 50,000 of them by next week. There have been serious problems with a lot of tests already released; British officials said on March 25 that they’d ordered more than 4 million tests that turned out to perform miserably, with many false negatives. Problems or uncertainty about test reliability has greatly delayed the availability of widespread antibody testing and the development, evaluation and mass production/distribution of a good test must be a major priority.
With so many potential tests being submitted, trying to get FDA evaluation is an unavoidable delay — some locales like Chester County Health Department in Pennsylvania have done their own evaluation of Adavite’s test and made the call to utilize it, allowing faster implementation. “Chester County is fighting the coronavirus crisis on many different fronts, and undertaking the antibody blood test for our essential personnel is another weapon in that fight,” said the Chester County Health Department Commissioners’ Chair Marian Moskowitz in a press release. “We chose to work with Advaite because our evaluations showed that the company’s test kits performed most efficiently and accurately.” New York state is following suit with their own developed antibody test.
These local initiatives once again point to local action as a major factor in the speed and efficiency of pandemic response. Locales that have taken their own initiative at validating and adopting tests have been able to implement them; states waiting for the FDA to do all the work are still waiting as the agency is buried under a huge mountain of applications to review.
Germany’s equivalent to the U.S. Center for Disease Control makes recommendations but does not set national policy for the entire country. Germany’s 16 federal states make their own decisions on Covid-19 testing because each of them is responsible for their own health care systems. While many US states and localities sat on their hands waiting for overwhelmed national agencies to do their jobs for them, Director of the Institute of Virology Christian Drosten at Berlins Charité hospital points out that “We have a culture here in Germany that is actually not supporting a centralized diagnostic system,” said Drosten, “so Germany does not have a public health laboratory that would restrict other labs from doing the tests. So we had an open market from the beginning.” A dense network of independent labs were called upon by state agencies (who each could conduct their own faster review of the testing) and were able to move much faster, focusing on testing in their own areas rather than states waiting for one beleaguered Federal Agency trying to solve it for more than 300 million people all at once. By mid February, Germany had ample testing in place nationally.
Testing more people with more effective tests greatly facilitates the Third Strategy, which is to re-start as much or our economies as we can as fast as can safely do so. First, let’s dispense with the recent poorly-reported ‘concerns’ about possible re-infection. Almost every virologist and epidemiologist in the world believes that although this is POSSIBLE and needs to be thoroughly explored, it is almost certain that these cases are NOT reinfection but are either due to faulty testing or more likely from reactivation of incompletely recovered patients. We still don’t really know how long Covid-19 really lasts in the body so reactivation is far more likely than re-infection, which is good because if re-infection were commonly possible we would essentially have to shelter in place and wait for a vaccine or really effective treatment to come along.
There’s also been a lot of debate about just how long immunity lasts, but even that debate is useless at the moment — immunity will almost certainly last at LEAST a few months, and most likely a few years. Anything in that range makes antibody testing useful to see who is recovered and immune enough to perhaps go back to work or care for Covid-19 patients more safely.
Germany is planning to try out ‘Immunity Certificates’ and U.K. Health Secretary Matt Hancock has even floated the idea of an immunity wristband. Admittedly there are many possible issues with immunity certificates allowing recovered people to return to work:
- Issues of patient privacy
- Non-infected/immune people desperate to work might actively infect themselves to be allowed to work (like the ‘Chickenpox parties’ we used to have)
- Enforcement and monitoring — a lot easier in a country like Germany with a population only 27% that of the US, in an area smaller than Montana
- Forged black market certificates would almost certainly arise
- Logistics of issuing, certifying people in a country of 380 million people
- Creation of a two-tiered workforce
Real concerns to overcome. However, these cannot be barriers, but instead challenges that MUST be addressed to allow parts of our economy and society to begin working again. Health workers and high-value, high-risk working should be prioritized but the second strategy — implementing widespread testing with cheap, reliable antibody tests — would reduce these ‘triage’ type testing decisions.
Giving privileges to people with immunity may be the price of getting the economy moving again. Allison Hoffman, a professor at the University of Pennsylvania who specializes in health-care law, suggests that “From a policy perspective, it’s not especially worrisome if the rest of the population has good unemployment coverage,” she says. “It would speed economic rebuilding, which I think everyone would want, whether employed or not.”
The reality is there is no way out of this without costs. That’s what we all have to face. We’ve already paid with a lot of lives and billions of dollars and the screeching halt of the global economy and society as we know it. There is no perfect, elegant way out of this — only the best decisions we can make, with the best evidence possible, moment to moment in this evolving situation to win the victory we envision with as little additional cost as we can manage. Waiting for the perfect solution because we aren’t willing to make a single mistake will ultimately cost us more in the end. We’re going to make more mistakes and we have to be willing to make them, learn from them, and quickly correct them
Obviously we can’t go on like this forever, with 600,000 Covid-19 cases (and counting),10 million Americans out of work and 2% of the entire US population filing for unemployment in just the first week of April. We’ve been in a disorganized retreat with 129,000 dead, elderly people found dead and abandoned in Spanish nursing homes, ice rinks converted to morgues, New York telling doctors to mentally prepare to triage who lives and who dies as they scramble for ventilators, and we prepare to soar past 1 TRILLION dollars in costs to an economy enduring the swiftest paralyzation any developed nation has ever seen. Right now we are still about damage control, a long way from reactivation of our economy and lives, with a million complicated questions to answer and challenges to overcome. A lot of tactical decisions to make.
But the strategy is simple, and local authorities should access whatever support they can from national agencies to achieve these:
- Fight the spread of infection as much as possible
- Test, test, test
- Restart whatever parts of our economy and society we can safely
And besides — as my team would undoubtedly say — just because they seem like impossibly huge and complicated tasks is no reason not to go ahead and accomplish them anyway!
“You know, there’s nothing remarkable about the fact that we went to the moon. We just decided to go.” -Apollo 13
