Sometime within the next few weeks, the federal government will have to make arguably the most far-reaching policy decision since World War II. The strategy of social isolation to mitigate transmission of the novel coronavirus has been in place for less than a month, and President Donald Trump is now suggesting most restrictions should be lifted by Easter, April 12, although no official decision has been made.
Based on data gathered in the next few weeks, scientists and policymakers will have three options:
— Continue current social isolation measures if they seem to be working.
— “Double down” and intensify this approach.
— Begin gradual relaxation of self-quarantining.
Nothing less than the health of the American public and the well-being of the American economy ride on this difficult decision.
So far, the results of social isolation have been less promising than hoped. In early March, the United States had about 1,000 cases (three per 1 million in population) of COVID-19, the disease caused by the coronavirus. That number now is now over 60,000. In early March, the U.S. had fewer than 25 COVID-19 deaths. Now, that number is over 900. Depending on the extent of unrecognized community spread of COVID-19, it could be plausibly argued that social isolation needs more time to show results; without it, things might be much worse.
Unfortunately, an unintended, although perhaps expected, consequence of social isolation has been virtual paralysis of the American economy. A month before measures were instituted, the Dow Jones Industrial Average flirted with 30,000. Now it has been hovering around 20,000. Comparisons to the Great Depression are no longer unthinkable.
Consider the quandary our decision-makers face: If social isolation were unarguably effective, or even if not, we could continue, perhaps even ramp up measures, so long as doing so did not result in a vise-grip on the economy. But unless the number of cases levels quickly, an economic recession is likely. If we intensify measures, a depression — something few Americans remember — becomes possible, creating a far more complex public health equation.
To date, epidemiologists have relied on graphs of new COVID-19 cases and deaths. But in a depression, other more difficult-to-count metrics in terms of physical health and mental health come into play. Things become more complicated. Health care is less affordable, and uncountable deaths may result. Just as important, people feel powerless and experience hopelessness. The resulting number of deaths from suicide, homicide, drug use and alcoholism may rise and must be measured against future COVID-19 deaths.
What to do? Models and graphs, while essential to understanding the future, do not predict the future. Policymakers will require all the information that they can amass in the next month to help them decide. But the debate and planning should start right now. There is no obvious right answer, and we may only know the right answer in retrospect. Could there be an acceptable middle ground that balances control of the virus and preservation of the economy?
Two key trends are emerging in the COVID-19 pattern in the U.S.
First, while much higher than the common flu, the mortality of COVID-19 is relatively low, currently 1.25% and probably lower if all “walking well” patients could be counted. The U.S. death rate from COVID-19 remains among the lowest of all Western industrialized countries. Those at risk are the elderly, especially those older than 80, and anyone who is immunocompromised or who has a serious chronic disease. Healthy young people have died of COVID-19, but it is extremely unusual.
The second trend is that this epidemic is actually two epidemics — one in a handful of states and the other in the rest of the country. New York and New Jersey comprise more than half of all American COVID-19 cases; the case rate per million population in these two states is more than 10 times that of the rest of the country. (Add California, Washington, Michigan and Illinois, and you have two-thirds of all American cases.) These high-incidence states may require a different federal approach and more local control than some of the Midwestern and southcentral states. What’s right for New York City may not be right for Des Moines, Iowa.
So perhaps a regionally directed policy should be considered. We could pull back mitigation in the least hard-hit areas, and observe the health and economic metrics. To provide an economic stimulus to areas where tighter measures remain in place, pull-back priority should be given to low-risk areas with critical industries and responsibility for delivering goods to the entire country. Include small businesses in the local pullback as well. Even low-risk areas must prevent large groups gathering at the same time. So implicit in any approach is that we must implement special policies to protect our high-risk citizens.
This strategy would mean travel restrictions to and from heavily hit areas to avoid importation of cases and carriers — unpleasant but essential. This regional approach could be reevaluated at three- to four-week intervals for its effect on disease mitigation and the economy. If this approach worked, other areas could be “opened up” gradually with similar caveats. If the approach is failing, the need to continue stringent social isolation would be unassailable.
Desperate times call for desperate measures. To succeed, our planners will require the fundamentals needed in any disaster: a command of the facts, good judgment, a healthy respect for uncertainty, strict devotion to infection control and public health details and flexibility.
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ABOUT THE WRITERS
Dr. Cory Franklin is a retired intensive care physician. Dr. Robert A Weinstein is an infectious disease specialist at Rush University Medical Center. The two worked together in Chicago during past flu outbreaks and the AIDS epidemic.
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