To my Patients and Friends,
I’ve devoted this installment to issues surrounding reopening strategies. Just a heads-up: it’s kind of an opinion piece, so feel free to shoot the messenger (euphemistically, that is)… but please recognize that my opinions are based on scientific evidence.
The current state of affairs
As you all know by now, certain regions of the country have begun contemplating (or even implementing) the loosening of physical distancing regulations and the reopening of businesses, religious and other organizations and public spaces. Nearly everyone has an opinion on these complex matters, and in the absence of clear and consistent federal leadership, state and municipal leaders have been taking it upon themselves to make decisions which they claim are in the best interest of their constituents (though politics permeates nearly every decision these days). Some of these leaders have approached such matters from a balanced, evidence-based perspective. Others- many facing pressures from multiple sides- have not.
I turn to the state of Georgia as perhaps the most glaring example of what I believe is frank negligence on the part of its leader. According to the reputable IHME model, a total of 53 COVID-19-related deaths are anticipated in Georgia by May 1, and current projections estimate 2,259 deaths by August 1. Despite all this, as his state’s COVID-19 case rate continues to climb and its coronavirus testing rate remains among the lowest in the nation, Governor Brian Kemp has authorized the throwing open of restaurant, gym, salon and theater doors. Many leaders in his own state and elsewhere worry that his plan will backfire, and that in a month or so from now, a new surge in COVID-19 cases may become apparent. And unfortunately, we can’t put a fence around Georgia; adjacent states- and eventually all states– will be affected by this reckless move as virus-laden individuals (most of whom will be most contagious during the early, pre-symptomatic days of the infection) get on buses and trains and planes. When experts like Dr. Anthony Fauci refer to second or third COVID-19 waves, decisions like this one are on their minds. Other states leaders, including those in Iowa, Nebraska, North Dakota, Oklahoma, South Carolina, Tennessee and Texas have made similar decisions.
At minimum, states should adhere to current federal guidelines as related to a data-driven, phased approach to getting us out of our homes and into the workplace. We need to get there ASAP, but we shouldn’t allow ourselves to throw all caution to the wind in order to get there too soon. We’ve all worked so hard to try to beat back this devastating virus… it’s imperative that we remain patient and keep our eyes on the ball. The words printed on a mere penny- E Pluribus Unum– have never meant so much. And we must demand good guidance and assistance from our federal leadership.
Testing the waters
Several models have indicated that we do not yet have sufficient testing capacity in place in order to safely move forward with these relaxation measures. Researchers at Harvard’s Global Health Institute analyzed the number of tests per day that would be necessary in each state by May 1 in order to safely begin to relax social distancing measures. They have determined that the majority of states have fallen well short of where they need to be in order to effectively monitor and track due cases of COVID-19. The IHME model (mentioned above), estimates that only West Virginia will reach the necessary testing and contact tracing thresholds by May 10, and more than 20 states will not have reached that point until the beginning of June or later. Connecticut is expected to reach the threshold on June 17.
Is there another side to the story?
Of course. For example, David Katz, MD, MPH, FACPM, FACP, FACLM (yes, that’s a lot of letters), an esteemed expert in matters related to public health and founder of the Yale-Griffin Prevention Research Center (and a guy who I’ve heard speak and for whom I have a great deal of respect), recently wrote a New York Times opinion piece entitled Is Our Fight Against Coronavirus Worse Than the Disease? In it, he argues that “if all we do is flatten the curve [without moving to a phase II], you don’t prevent deaths- you just change the dates.” He summarizes his balanced “bridges-not-bunkers” approach in this well-conducted interview, in which he argues that we can aim to protect the most vulnerable among us and keep our health system from being overwhelmed while we return to a new normal. Although he articulates his perspectives elegantly, I struggle with a couple of his main premises. In the context of our tragic failure to gear up for mass testing as other countries have done successfully, he argues for making do with our current testing supplies by performing representative random sampling as a next-best alternative. My concerns with this model are that it ignores the fundamentally insidious (and still poorly understood) biology of the coronavirus and that many cases will inevitably be missed, the implications of which could be exponential and devastating. We’ll still need to perform lots of tests in order to reliably extrapolate the sample results to the larger population. He also proposes defining two basic sub-populations to be isolated from one another: those of us who are at low risk for complications from COVID-19 (who should be allowed to return to school, work, malls, etc.) and those who are at high risk (who should remain cloistered). To me, this seems not only dystopian but nearly impossible. But there are many smart people who espouse this type of approach, and they need to be part of the conversation.
Here’s another smart discussion of some of the important considerations for reopening, particularly as related to testing and contact tracing.
Keeping your cool
An amusing mashup
Check out this clever and timely mix of clips from one of the best sitcoms ever produced.
That’s all for today. Please continue to stay home, stay calm and stay well! See you soon.