The United States has a narrow window of opportunity to determine the fate of its coronavirus crisis. Will we end up looking like Italy or South Korea?
Italy’s health system has imploded under the strain of new cases and the shortage of ventilators means doctors must make agonizing decisions on who to save and who to let die. In contrast, South Korea acted swiftly and boldly to “flatten the curve”— the government did everything it could to slow the rate of increase and so reduce the burden of the illness on the country’s clinics and hospitals.
Right now, the number of new cases of confirmed infection in the U.S. is doubling every four days. This puts us on a trajectory towards becoming Italy. On March 16, a research team at Imperial College London published a new study suggesting that without taking control measures, there would be about 2.2 million deaths in the U.S.
We could still avoid this catastrophic scenario. We will need to act urgently, ruthlessly, and aggressively to adopt five key measures that helped to flatten the curve in places like Japan, Hong Kong, Singapore, and South Korea.
- Testing, Testing, Testing
The nationwide shortage of coronavirus test kits here in the U.S. is not just a disgrace, it is emblematic of a country totally ill prepared to fight a deadly pandemic. Right now, with so little testing, we are shooting in the dark when it comes to our control efforts. It’s the equivalent of a surgeon trying to do an operation with the lights off.
Why is it so critical for us to have a massive surge in testing? People who are sick need to get the right diagnosis and clinical care. We know, for example, that if you are hospitalized with COVID-19, there’s a high chance you’ll need transfer to the intensive care unit.
People with mild symptoms who get tested can self-isolate and help stop the spread of the virus. If one person has the disease, we can then test those they have been in contact with (known as “contact tracing”). In other words, testing and contact tracing can help to break the chain of transmission. As Dr Tedros Ghebreyesus, the World Health Organization’s director general, says: “Find, isolate, test and treat every case, and trace every contact.”
Testing also allows clinics and hospitals to become better prepared, as they know how many cases to expect. And, crucially, testing helps us to know where the disease is, how it is evolving, and where to target our efforts to control it. It identifies the hot spots of infections.
Countries that have flattened the curve made testing widely and freely available, using innovative approaches like mass drive-thru test centers. South Korea has been conducting around 12,000-15,000 tests every day, and has the capacity to do 20,000 daily. While it is hard to get accurate estimates, the CDC reports that only around 25,000 tests have been conducted in total nationwide by CDC or public health labs in the U.S.—compare this with the roughly 250,000 tests that South Korea has done to date.
We are seeing promising signs in the right direction. The House just passed a bill that guarantees free testing. Target, Walgreens, CVS, and Walmart will soon offer drive-thru testing. The CDC promises to ship out more test kits to state and local public health labs and it has relaxed its guidelines on who can get tested. But test shortages remain, and we’re still playing catch up.
2. Communicate and coordinate
There’s one striking message from a new analysis of how Hong Kong, Singapore, and Japan were able to contain COVID-19. In all three locations, there was excellent communication and coordination between different government departments and between the central and regional governments.
In Singapore, for example, “there are almost daily meetings between Regional Health System managers, hospital leaders, and the Ministry of Health.” Clear COVID-19 plans and protocols are in place so that all key players at all levels of the health system know what they are supposed to do. There’s also explicit, detailed information given daily to the public on the state of the outbreak.
Unfortunately, in the US, the COVID-19 response led by Vice President Mike Pence has suffered from extremely poor communication from the outset. The flailing Trump Administration downplayed the threat from day one and Trump himself has stated many factually incorrect things about the virus. There is still no clarity on who is responsible for what. With very little clear and credible guidance from the federal government, cities, counties, and states have had to do their best on their own.
3. Use social distancing to protect the vulnerable
Most of the transmission in the U.S. is happening within our borders (so-called community transmission), which is one reason why Trump’s travel ban is now so pointless.
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A critical tool for breaking this community transmission is “social distancing”—staying away from places where people congregate (movie theaters, bars, restaurants, shopping centers), avoiding mass gatherings (like religious services and concerts), and maintaining a distance of at least six feet from other people. Countries that flattened the curve have taken a variety of approaches to breaking community transmission, from school and office closures to suspending public transportation.
People can transmit the virus without knowing they are infected. When we decide to have a beer or cocktail at our favorite crowded bar, we could end up spreading the coronavirus to our friend, who then transmits it to their aging mother who has heart disease and who could end up getting sick or even dying. We are all potential links in the transmission chain, which is why social distancing is so important.
Although the CDC left it extremely late, it finally issued guidelines recommending that there should be no gatherings of 50 people or more. That’s a small step in the right direction, but it does not go far enough. The guideline “does not apply to the day to day operation of organizations such as schools, institutes of higher learning, or businesses.”
Trump himself went further saying people should avoid groups of 10 or more, but his guidelines “are not mandatory and fall short of a national quarantine and internal travel restrictions, which many health officials had urged.”
The poor communication and coordination between the federal government and states means some states have started to adopt social distancing approaches, but others have not—so it’s luck of the draw when it comes to whether you’re at risk. In North Carolina, where I live, for example, decisions to close schools were initially made on a county-by-county basis, creating a confusing patchwork of closures. On Saturday, Gov. Roy Cooper finally stepped in and ordered all of the state’s public schools closed for at least two weeks. Similar inconsistencies abound among cities’ and states’ bans on public gatherings. If social distancing has a hope of working, we need to apply it uniformly.
4. Protect our health workers
Our most precious resource right now is our health workers. Along with our botched roll out of coronavirus testing, we should also be ashamed of how we have broken our promise to protect these heroes—our national shortage of protective equipment means doctors, nurses, physical therapists, and other front-line workers are getting infected and risk death. Two emergency physicians, one in Washington state and one in New Jersey, are now in critical condition with COVID-19. Such infections also put even more strain on the health system, and continue to fuel the cycle of transmission.
Rapidly scaling up and deploying the production of protective equipment for health workers is not just a public health necessity. It’s also a moral emergency. What kind of a nation are we if we can’t protect those who are literally putting their lives on the line night and day to care for our sick?
5. Expect and plan for a rise in cases
As Dr. Anthony Fauci, director of the National Institutes of Allergy and Infectious Diseases, has warned, “things will get worse than they are right now.” Every health care setting across the country, especially hospitals, should take steps now to prepare for a rise in cases, including scaling up their supplies of equipment such as ventilators. It was therefore disheartening to hear Trump tell governors yesterday, “Respirators, ventilators, all of the equipment — try getting it yourselves.” The federal government needs to step up at times like these. There needs to be an emergency injection of funding to expand our strategic national stockpile of ventilators.
All in all, it’s too soon to throw in the towel and accept an Italian scenario. With five key measures—testing and contact tracing, communication and coordination, social distancing, protecting health workers, and health systems planning—we could still become South Korea.