On January 19, 2020, a previously healthy 35-year-old man presented to an urgent care clinic in Snohomish County, Washington with a 4-day history of a cough and subjective fevers. He had just returned from visiting family in Wuhan, China, where a previously unknown viral illness was infecting large numbers of people. Testing for that novel coronavirus (now known as SARS CoV-2) came back positive on January 20—the first documented COVID 19 case in America.
On January 22, during a press conference in Davos, Switzerland, CNBC’s Joe Kernan asked President Trump, “Are there worries about a pandemic at this point?” The president responded, “No. Not at all. And we have it totally under control. It’s one person coming in from China, and we have it under control. It’s going to be just fine.” It was Trump’s first public comment about the virus. It would not be his last.
In early February 2020, the U.S. unemployment rate stood at 3.5%--the lowest level in 50 years. That seems like a lifetime ago. A White House economist recently projected that U.S. unemployment might hit 20% by June, as entire sectors of the nation’s economy have been shut down in response to the spread of COVID 19. Restaurants are shuttered, airlines virtually shut down, and hotels are empty across the country. There are no concerts and no sporting events. We have all become experts in things like social distancing and the judicious use of hand sanitizer. Masks, no longer merely the preferred attire of bank robbers and movie superheroes, have become ubiquitous these days.
But here we are, with perhaps a little light at the end of a very dark tunnel, finally thinking about how we can take the first faltering steps back towards some semblance of normalcy.
It’s a tantalizing prospect. We all crave so many things that we took for granted just a few short months ago. But reopening the economy is not without risk. Do it too soon and you risk another spike in cases, potentially costing thousands of people their lives and further stressing an overtaxed health care system. Do it too late and the nation’s already struggling economy could be crippled even more. It’s a balancing act I call the “Goldilocks Phenomenon,” after the classic fairy tale. In other words, when it comes to reopening the economy, is our situation too hot, too cold or just right?
The ideal post-pandemic economic reopening would, of course, strive to achieve that sweet spot of “just right,” but hitting that mark may be difficult. Unfortunately, we will only know if we were right or wrong in retrospect. It’s a grim calculus, weighing lives saved against livelihoods—and there are potentially deleterious consequences if errors are made in either direction, as evidenced by a recent Penn Wharton Business School study (https://www.usnews.com/news/economy/articles/2020-05-01/reopening-the-economy-would-add-233-000-deaths-by-july-but-save-millions-of-jobs).
Governor Brian Kemp of Georgia received national attention when he began easing lockdown conditions in Georgia last week, allowing hair salons, gyms, tattoo parlors and bowling alleys to open. Seated restaurant service was allowed this week. Kemp’s actions warranted closer examination in the New York Times, which ran an article specifically delineating “Why Georgia isn’t ready to reopen” (https://www.nytimes.com/interactive/2020/04/24/opinion/coronavirus-covid-19-georgia-reopen.html). On April 24, Fortune magazine published an article revealing an artificial intelligence program that described Georgia’s Chatham County and Clarke County as two potential COVID 19 “hotspots” likely to see a surge in cases in the next two weeks (https://fortune.com/2020/04/24/coronavirus-hotspots-us-states-reopen-economy/). But Governor Kemp defended his actions by saying that he was basing his response on the advice of his scientific advisory team—and the available data provided by the Georgia Department of Public Health do show a definite declining trend for both new COVID 19 cases and COVID 19 deaths in the state (https://dph.georgia.gov/covid-19-daily-status-report).
So how, and when, can the economy safely reopen? How can we achieve an ideal outcome in regard to the Goldilocks Phenomenon, getting the economic re-opening “just right?”
As one examines the potential consequences of easing the lockdown, there are three significant factors about SARS CoV-2 that play a role. First, about 25% of people who have it may be completely asymptomatic. Think Typhoid Mary (look it up if you don’t get the reference) and you’ll see the significance of this. Second, the disease is highly transmissible—about twice as contagious as the flu. Third, the mortality (death) rate of people infected is estimated to be around 1 percent, which means that if there is a large, uncontrolled outbreak, a lot of folks will be hospitalized—and many, many people will die.
The first priority is, of course, the potential toll on human life. COVID 19 has now killed over 64,000 Americans. That’s more than the number of Americans who died during the entire Vietnam War. But it could have been much worse: The first estimates of the virus’s potential death toll in the U.S. was several hundred thousand. Social distancing measures, the regular use of masks, and the cancellation of non-essential events bought us time, allowing us time to strengthen our reserves of personal protective equipment (PPE), acquire stockpiles of medication and equipment and perform more research into ways to improve survival with the virus. There is no question whatsoever that these efforts saved untold numbers of human lives. One only need look to Albany, a town in southwest Georgia of about 78,000 which is 183 miles from Savannah as the crow flies, to see what might have been. Two funerals in town early on in the pandemic led to the state’s worst outbreak on a per-capita basis—a total of 1506 cases in Dougherty County so far, or 1675 cases per 100,000 people, and 120 deaths.
Any measure of the virus’s effect on a given population has to include the indirect effects, as well. In Northern Italy, New York City and Wuhan province, overwhelmed health systems had higher death rates from other conditions, such as heart attacks, strokes and the like, due to the depletion of health system resources by the sheer volume and acuity of COVID 19 patients. But lockdowns cause negative collateral effects themselves. Domestic violence complaints and mental illness issues have spiked, and experience with similar lockdowns has shown that substance abuse and PTSD can be late consequences of social isolation. The recent suicides of two New York health care workers caring for COVID 19 patients has only underscored the inherent mental health risks of the pandemic. And the economic toll has been astounding. 30 million Americans who were working in February have now filed for unemployment. The White House estimates that the U.S. GDP contracted at an annualized rate of 4.8% during the first quarter of 2020, the first quarter of negative GDP growth in 6 years. The second quarter figures are certain to be far worse. Business interruption and the consequent job losses have led to significant financial distress for many families. Many small businesses will likely not survive the pandemic-induced economic cataclysm.
There are a few basic criteria which must be satisfied when any region is considering post-COVID economic re-opening (https://www.whitehouse.gov/openingamerica/#criteria). First, as delineated by the White House pandemic task force, a region re-opening after the pandemic needs to see at least 14 days of declining cases. That’s one viral cycle (the incubation period for COVID 19 is 2-14 days). Second, any region re-opening needs to have adequate hospital bed availability, ventilator and ICU bed availability and an adequate stockpile of personal protective equipment (PPE) to accommodate employee needs during any local surge in cases. Third, there needs to be ready availability of COVID 19 testing capacity so that anyone who needs to be tested (and especially health care workers) can obtain a test without delay. Finally, the region needs to be able to do the basic epidemiologic work required to squelch any spikes in disease activity, by doing efficient contact tracing of any known cases so that potential exposures are isolated and quarantined.
So how are Georgia and Chatham County doing with regard to these criteria?
According to the Georgia Department of Public Health, when one looks at the rolling numbers of confirmed cases, it appears that COVID 19 cases in our state may have peaked around April 13—over two weeks ago. Of course, the validity of that number may be called into question by Georgia’s low testing rates. Low testing rates might mean that the actual case counts far exceed the measured ones. For example, if 3 people are positive in an area in which 1000 people have been tested, that’s much more likely to be a true representation of disease prevalence than 3 people testing positive in a region which has only tested 10 people. As of May 1, only 1.6% of the Georgia’s total population has been tested—one of the lowest rates in the nation. The Harvard Global Health Institute has determined that a testing rate of 152 tests per 100,000 people per day needs to be achieved to identify all of the people who are infected and isolate them from those who are healthy (https://globalepidemics.org/2020/04/18/why-we-need-500000-tests-per-day-to-open-the-economy-and-stay-open/). Georgia has not hit that mark yet, but we’re getting close; the most recent figures showed 122 tests per 100,000 this past week.
Locally, things are getting better on the testing front. Both local hospital systems can now perform in-house COVID 19 PCR testing, making results potentially available in hours. Testing availability and turnaround time are much better than they were earlier in the pandemic.
According to the IHME database from the University of Washington, Georgia is past peak for both resource utilization and bed availability (https://covid19.healthdata.org/united-states-of-america/georgia). Statewide there is not currently a hospital bed shortage, a ventilator shortage nor an ICU bed shortage. That is true locally, as well. Both hospital systems have more than enough beds and ICU capacity to tolerate a surge in cases.
The local PPE shortages that were seen earlier in the pandemic have now been rectified. Both hospital systems report having stockpiled enough PPE to accommodate their full complement of staff.
One additional area that Georgia appears to be lagging is in the capacity to perform contact tracing. Georgia Public Health Commissioner Kathleen Toomey recently said that Georgia has 400 public health authorities doing contact tracing but admitted that this number falls short of a target value of 1000. Utilization of an opt-in cell-phone Bluetooth-based contact tracing system, similar to those which have been utilized in China, Singapore and Taiwan, is also being investigated. Apple and Google are working together on such a system and are expected to roll out the first version sometime in May—but that’s just one data access tool, and it does not replace the human beings who must analyze the acquired data. Clearly, the state has more work to do in this area.
Where do we go from here?
First of all, let’s get one thing straight: I am not Nostradamus. I have a medical degree, but no crystal ball. However, there are a few things I can safely predict, based on the data we are seeing now.
First, we are clearly moving from the mitigation stage of this pandemic to containment. Nationally, the trend of new COVID 19 cases has a downward trajectory, and the numbers of both cases and deaths have both peaked. Lockdowns are being lifted, and we are all grateful. That being said, we must remember that this virus is very, very contagious—and it is estimated that less than 3% of all Americans have been infected. There is therefore no “herd immunity” out there, which typically occurs only when about 60-70% of a given population has been exposed and/or developed immunity via vaccination. Outbreaks can, and will, occur. For this reason, until a vaccine is widely available (which will most likely be over a year away), many of the precautions we have all been using for the last few months will likely remain in place. Social distancing will remain a thing. Hand-washing, sanitizing, extensive surface cleaning and widespread facemask utilization will continue. Large public gatherings will be limited. Exposures to infected persons will result in some people being intermittently quarantined for the benefit of everybody else. We must all be prepared to put up with these inconveniences if life is to remain somewhat “normal” during the pre-vaccination stage of this pandemic.
Second, clinical outcomes for COVID 19 patients will improve. We are seeing torrents of data about management of these patients in the medical literature now. Clinical strategies for COVID 19 patients change almost daily. The general public is seeing a telescoped view of how the medical community shares information and alters its disease management strategies based on hard data. It’s quite an efficient, statistically-driven system—and we are seeing it at its best right now. For a disease caused by a virus that no human on earth had ever heard of before Thanksgiving to have this much information available in its management in a mere six months is simply extraordinary. There will be some treatments coming out of this which will alter patient outcomes for the better—in fact, there already are (https://www.buzzfeednews.com/article/danvergano/fda-remdesivir-coronavirus).
You can bank on more of this sort of thing going forward.
Third, there will be a SARs CoV-2 vaccine, perhaps several—and it will likely be a game-changer. Human trials have started on vaccines which were effective in preventing infection in rhesus monkeys. One vaccine, from researchers in Oxford, England, may be ready for commercial use by the fall of 2020 (https://www.france24.com/en/20200430-high-hopes-for-covid-19-vaccine-developed-by-oxford-scientists). This sort of intervention is, perhaps, the best hope we have for a true return to what we used to call “normal.”
The entire human race is walking an epidemiologic tightrope right now, trying to strike the sort of balance that Goldilocks would be proud of. It's a difficult proposition, but one which can be made with the judicious use of data, some common sense, and more than a little bit of luck. The decisions are made locally, but the cumulative effects will certainly be felt globally.
Here’s hoping we can get it "just right."