China did it. Thailand, Laos, and Vietnam did it. New Zealand even brought its caseload down to zero.
How can the US turn its response around?
Unfortunately, there is no one simple solution, says Tom Frieden, MD, MPH, the former director of the CDC and current president and CEO of Resolve to Save Lives, an initiative of Vital Strategies. It will require conducting widespread testing, masking up, isolating or quarantining infected people, tracing their contacts, and doing other essential steps to bring the virus under control. “We need a comprehensive response, and we’re going to need to do different things in different places at different times,” Frieden says.
These decisions must be based on data that must be “accurate, accessible, and actionable,” but the US is failing on data collection. Resolve to Save Lives released a report on Tuesday identifying 15 essential indicators that states should be tracking in real time. Currently, no state tracks all of them. Not one state is satisfactorily reporting performance metrics related to contract tracing programs that the report suggests—such as the share of cases arising from quarantined contracts.
Scientific data must also inform leaders’ actions and communications, says Tom Inglesby, MD, director of the Johns Hopkins Center for Health Security.
“Political leaders who have very, very influential voices have the ability to change things,” says Inglesby. “If they decide to move against science or call it into question … that’s going to continue to confuse people.”
That means owning up to the facts. For example, right now it is clear that in some states, the disease is spreading fast enough that testing and contact tracing are no longer realistic strategies to contain the virus, said virologist Angela Rasmussen, PhD, an associate research scientist at Columbia University’s Mailman School of Public Health. “We need to reinstitute stay-home orders to reduce community transmission to the point that test and trace containment is feasible,” a strategy that also requires financial support to enable people to stay home, says Rasmussen.
“We Have to Be Frank”
Testing capacity also needs to be scaled up, but this, too, requires data. Governors, for example, need to understand what is causing backlogs in their states. Is it shortages of swabs or reagents? Delays in moving samples from clinic to lab? Other problems?
Until there’s more transparency, Inglesby notes, “It’s going to be hard for states to deal with it.”
In the meantime, notes Frieden, limited testing capacity means prioritizing people with symptoms and members of vulnerable populations. “We … have to be frank,” says Frieden. “We don’t have enough tests, we do not have enough PPE [personal protective equipment], and therefore, we need to prioritize.” To deal with the shortage of disposable masks, for example, he advocates scaling up the use of reusable masks such as powered air-purifying respirators and elastomeric respirators, which, he admits, are not ideal.
To address shortages on all fronts, the government can leverage tools such as the Defense Production Act to ramp up production of PPE and allocate manpower to places where it is needed, such as laboratories that are backed up processing SARS-CoV-2 tests, says Nahid Bhadelia, MD, MALD, an associate professor of medicine at Boston University School of Medicine and a physician at Boston Medical Center. The government should also be investing in new technologies, such as point-of-care testing that provides immediate results, she says.
All of this requires more funding, notes Georges C. Benjamin, MD, executive director of the American Public Health Association. He believes the $3 trillion bill passed by the House in May approaches the amount needed to address the pandemic, although the Republican-controlled Senate is unlikely to pass a bill of that size.
“It’s going to cost us, we’re going to have to pay it back,” Benjamin says. “But it’s much easier to fix it now than fix it later, and cheaper too.”
“Box It In”
A comprehensive coronavirus response requires planning for the short-, medium-, and long-term. Eventually, Frieden notes, virus cases in the South will go down, and officials there must prepare for the next phase: how to contain the virus, or “box it in.”
And in 6 to 12 months, he adds, it’s likely a vaccine will be available, but leaders also need to plan for how to communicate to people about it. That means being open “about all that we’re learning about the vaccine, so that there’s no paranoia or suspicion,” Frieden says.
Bhadelia notes that reaching some populations with public health messaging may require more dedicated engagement. “You always find pockets of communities that are highly resistant,” she says. “Go to the community stakeholders of that area and try to personalize the outreach.”
Benjamin cites the examples of masks—while he advocates universal masking, he knows that mandates won’t always work. “People don’t like to be told what to do,” he says. “You need to get out and push it, promote it, make it cool.”
He would also like to see officials focus on the populations that have been especially hard hit by the virus, such as low-income people and communities of color. “We need to pay a lot more attention to the health inequities that we have here,” he says.
None of this is possible without “principled national leadership,” Benjamin stresses. Unfortunately, he says, “the leadership piece is the hardest to fix.”
"All in This Together"
Installing a national coronavirus “czar” would not necessarily solve the problem, unless that person was brought in “expressly to manage and coordinate” the many different moving pieces of the response, says Rasmussen. Given the heterogeneity of the virus’s impact, she emphasizes giving local leaders flexibility and autonomy to manage their responses based on evolving conditions. Inglesby is encouraged by leadership at the state level. Governors from both parties have in some states worked hand-in-hand with public health officials, he notes.
Frieden, for his part, is taking his message to media organizations across the political spectrum, writing for and appearing in outlets including Fox News, The New York Times, CNN, and MSNBC.
“The virus doesn’t discriminate by politics,” he says. “I want everyone to know we’re all in this together.”
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