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There’s no point in sugar-coating this. The U.S. response to the Covid-19 pandemic is a raging dumpster fire.

Where a number of countries in Asia and Europe have managed to dampen spread of the SARS-CoV-2 virus to the point where they can consider returning to a semblance of normalcy — friends from Paris just emailed me pictures from their Sicilian vacation — many international borders remain closed to Americans.

On Sunday, Florida reported more than 15,000 cases — in a single day. South Korea hasn’t registered 15,000 cases in the entire pandemic to date. One day last week the U.S. recorded more than 68,000 cases.

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The website Covidexitstrategy.org has updated its previously tri-colored U.S. map, which showed states as either green, signifying they are trending better; yellow, making progress; or red, trending poorly. A fourth designation, called “bruised red,” signals states with uncontrolled spread; criteria for this category includes hospitals nearing capacity both in terms of overall beds and ICU space. Already 17 states are wearing bruised red.

The virus suppression gains earned through the painful societal shutdowns of March, April, and May — the flattened epidemiological curves — have been squandered in many parts of the country, dejected public health experts agree. A vaccine for the masses is still months away. What can be done?

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One thing is clear, according to public health experts: Widespread returns to lockdown must be a last resort — and may not be doable.

“It would be really a morale breaker,” Anthony Fauci, director of the National Institute for Allergy and Infectious Diseases, told STAT. “The stress and strain that people were under during prolonged lockdown is the genesis of why, when they were given the opportunity to try and open up, they rebounded so abruptly. Because what I think happened is, they overshot.”

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But this is not a binary choice between societal lockdowns and the “party like it’s 2019” approach that put the country in the bind it’s in now. With that in mind, STAT asked a number of public health experts for a single suggestion of how we get ourselves out of this mess. We got lots.

None is a magic bullet. This is going to be a painful and slow process. But there are things individuals, public health departments, state and local governments, and the Trump administration can do.

The fire brigade needs us all.

Turn the clock back

Pent-up people embraced newfound freedoms over-exuberantly, Fauci said. He suggests going back to Phase 1 of the reopening process and then working forward with more caution. “Do it the way they should have done it in the beginning,” he said.

“If we do that, particularly closing the bars, avoiding anything that has a congregation of a large number of people, wearing masks outside essentially all the time, keep distancing … I would almost guarantee that we would see a turnaround of the resurgence that we’re seeing now.”

Embrace al fresco living …

Ashish Jha, director of Harvard’s Global Health Institute, favors banning all indoor public activities that bring together groups of people, for now — including church services.

“My best read of the data is that a large chunk of the transmission is happening when people gather indoors. So, cut out the indoors. No restaurants, no bars, no nightclubs, obviously no schools right now,” Jha said.

He’d close stores, except pharmacies and grocery stores, and require those to limit the number of people they admit at any one time. Staff and customers would have to wear face coverings.

… but tailor tools to local settings

Saskia Popescu, an infection prevention epidemiologist at the University of Arizona, thinks advice like this needs to be pragmatic and take into account that conditions vary across the country. Like where she lives, in sweltering Phoenix.

“Everyone likes to say ‘eat outside!’ she notes. “You can’t do that in 115 F heat, so let’s give people the tools to apply infection prevention strategies for these environments.”

“Social responsibility is huge, but if we don’t do effective risk communication and education, you’re failing people,” Popescu said.

Get creative with risk communications

Marm Kilpatrick listens to a lot of NPR. On NPR, he hears a lot of public service announcements from the Centers for Disease Control and Prevention urging people to cover their coughs, wash their hands, practice social distancing. Kilpatrick, an infectious diseases dynamics researcher at the University of California, Santa Cruz, thinks most of that advice is, by now, not useful.

People should be wearing masks, so by definition coughs are covered. (Plus, people who are coughing should be staying home.) Fomites — viruses coughed onto surfaces — are no longer thought to be a major mode of transmission. And people don’t really get how to social distance except “avoid strangers,” he said.

They need better, more useful messages telling them how to do the things they want to do, but safely. Kilpatrick gives it a go: “Wear a mask. Meet outside. Give space.”

Teach people to think in terms of harm reduction

“One thing I notice is that when people ask me a question, they say ‘yet.’ ‘Can I do this yet?’’’ said Amesh Adalja, an expert on emerging infectious disease and pandemic preparedness at Johns Hopkins. “And I say, ‘There is no ‘yet.’”

He suggests borrowing a page from the harm reduction work that has been done to address sexually transmitted diseases and the opioid epidemic — helping people figure out the risks they face and how to navigate them.

“We have to get better at individual risk calculus,” Adalja said. “It’s not something that people are very good at. And I think that’s why when bars opened in certain places it was like the whole town turned 21.”

Accept that for now the virus has the upper hand

We need to learn to live with SARS-CoV-2, said Michael Osterholm, director of the University of Minnesota’s Center for Infectious Diseases Research and Policy.

Pretending the virus is not a threat or trying to will it away is a recipe for disaster. “You have less chance of winning a policy debate against this virus than you do of … winning a debate against 2,000 angry 2-year-olds,” Osterholm said.

“People have to understand that. It’s like trying to defy gravity. Just because you want to doesn’t mean you can.”

Mine the data more efficiently

Public health is amassing lots of information about who is getting sick and where they’re getting infected. That data should be put to better use, said Caitlin Rivers, an assistant professor of epidemiology at the Johns Hopkins Center for Health Security.

“We can use that information to better direct resources and interventions, for example by closing high-risk activities rather than broad shutdowns,” Rivers said. These kinds of analyses will need to be ongoing, because conditions will change, and should be made public to help people assess their personal risks and guide their decision-making.

Cloudy with a chance of Covid

Data mining could be used to develop local forecasting services, said William Hanage, an epidemiologist at Harvard’s T.H. Chan School of Public Health.

He envisages something like: “Covid activity in your area is currently low. While the risk is not zero, all you need to do is wear a mask while indoors in a public space,” or “Covid activity is expected to be very high and you are advised to shelter in place. Please avoid contact with at-risk persons.”

Consistent consistency

Enough with the “but the flu” and “it’s getting better” and “it’s going to go away on its own” talk. There needs to be consistent communications from all levels of government about the risk the virus poses, said Alessandro Vespignani, director of the Network Science Institute at Northeastern University.

“I know it sounds trivial,” Vespignani said, “but I have the feeling that is impossible to win the fight if a large fraction of the population is not believing there is something to fight.”

Cut out the politics

With more than six months’ worth of experience with Covid-19, the world has good evidence about what works to suppress spread of the virus. All levels of government should be urging people to take those steps, said Tom Inglesby, director of the Center for Health Security at Johns Hopkins.

“If leaders from this point forward spoke with the same messages, consistently, clearly, without division, they likely have the power to change the views of many who have been less convinced of the right things to do because of conflicting, confusing messages they have been hearing,” he said.

Leaders should also practice what they preach — masks in public, avoiding large gatherings — and be guided by science, Inglesby said.

Provide more help for the hardest hit

Black, Latinx, and Native American communities have been disproportionately hard hit by this pandemic, said Richard Besser, president and CEO of the Robert Wood Johnson Foundation. And too little has been done to ensure that essential workers, many in low-paying jobs, have the tools to protect their health and the health of their families and communities.

Fixing this means providing income support so people who are sick or exposed can stay home, and ensuring they have sick leave and family medical leave. It also means funding unemployment insurance for the millions of people who have lost their jobs in the pandemic, and extending rent forgiveness and moratoriums on evictions and foreclosures, Besser said, as well as providing safe places for people who need to isolate or quarantine but don’t have the space to do it at home.

Pop-up testing sites

Natalie Dean said more geographically focused testing would turn up cases that are being missed. And bringing the tests to where the people are would result in a lot more people being tested. Dean, an assistant professor of biostatistics at the University of Florida, said more mobile testing vans could help identify where transmission is happening. That’s a different approach than the efforts to find and quarantine people who have been contacts of confirmed cases.

“So, it is less about using tracing to reconstruct a chain, and more about identifying a hot spot and trying to flood the area with tests,” she said.

Daily home testing, on Uncle Sam

Low-cost — $1 a day or less — home testing for Covid-19 is doable, said Michael Mina, a Harvard epidemiologist and associate medical director of clinical microbiology at Boston’s Brigham and Women’s Hospital.

“The tests exist. The technology exists. They could be manufactured tomorrow and they would detect people on the days that they are most likely to be transmitting,” Mina said.

These tests aren’t as sensitive as laboratory tests — they miss some cases — but they have the advantage of giving an instant answer. The turnaround for lab testing can be a week. If everyone in a high transmission zone could test themselves daily and stay home while they test positive, it would dramatically lower transmission, he said, arguing the government should pay for these tests.

Contact tracing, with national support

Too few states have the capacity to do effective contact tracing, says Crystal Watson, an epidemiologist at the Johns Hopkins Bloomberg School of Public Health.

“We need this capacity now and we will need it in the fall,” said Watson, alluding to the fact that Covid-19 and influenza will be co-circulating as we get into the autumn and winter. “The White House should embrace a national initiative for contact tracing, and Congress should provide additional funding for state and local public health authorities to expand contact tracing capacity.”

  • What a great article and a dose of reality. I just wish there was some way our president would listen. He won’t, and that is incredibly depressing.

  • No one put out the fire. It is impossible if a president adds gasoline to the fire of credibility. He is interested in elections, not people, except that people say they vote for him.

  • Science,not politics…Whenever and where ever we can get truthful information. That’s what we’ll listen to and follow. Do not be intimidated.

  • Like I said, Dumbest Generation, However entrenched thought did not stop Elon Musk, an amazing exception.

  • Great info. Helpful. It should be strrssed more by Admin’s Task Force. We NEED this!

  • It seems to me to be old fellas with limp dicks who are the problem here. The youngsters would throw every weapon in the technological arsenal at it. They’d harness massive datasets, they’d use our GPS data (everybody has a smartphone, they all have a GPS in them), they’d use constant contact via electronic messages, they’d have an app that traces contact. As they’ve grown up in an era where the economy is screwed and everybody has to help everybody, they’d open source things, they’d stay focused on the goal and work together, creating a culture of ideas rather than a culture of interest.

    The problem isn’t the kids; the kids are alright. The problem is old people still being in charge with their billionaire cronies and their culture of interest.

  • The epidemiologists have not covered themselves in glory in this pandemic. It has been the worst of publicity seeking and figuring nobody ever got fired for being too conservative. A real modeler would use the very uncertain data not for public consumption but to identify areas where improved data is required (i.e. testing, laboratory work) and how to target certain populations.

    How about we pull the grants from any group that put out public projections more than +/- 50% of actual data? Might be a good incentive to behave more like public servants than as the British Government noted “Court Astrologers”

    The Politicians job is to balance all the competing needs of society. For so-called “Scientists” to make light of that while clamoring for more funding is appalling.

    • This has been pointed out since the very beginning by several epidemiologists and virologists. It is about the data and getting meaningful, accurate metrics. Instead policy has been driven by wild, inaccurate estimates published in non medical media by journalists. The flip flopping on policy by politicians out of their element and driven by partisanship has been and remains a disaster.
      This is worse than the flu but hardly anything that ought to have stopped the economic engines of the world. As has also been pointed out in journals and on medical sites (though not in mainstream news sources) we know the cost of poor economies on health and mortality. Rather than take a thoughtful, measured and adaptive approach we get good narratives and shaming of anyone who asks a sincere question that might lead other than where the slight of hand leads the herd.
      Now we are seeing ‘outbreaks’ of as few as 3 cases trumpeted in regional media. Massive amounts of testing is happening and the numbers of new cases is highlighted in the same way that number of deaths (with no nuance about the age/underlying conditions associated with the majority) were blared at us to panic the herd. Of course more cases are popping up now that we are testing many more people…what’s the mortality rate? Given that we don’t test for flu and a ‘flu death’ is not necessarily reported as flu but often classed by an underlying condition can we do any meaningful comparison (per the CDC 2019/20120 flu deaths are anywhere from 24,000 – 62,000, in other words the high end of the estimate is more than double the lower number making it statistically useless).

      COVID is a virus to be concerned about, and it is a useful dry run for a true deadly pandemic. At the same time the annual flu is worth trying to combat through common sense precautions too; possibly more so if we start to gather data about flu with the same mania as with COVID. Who knows? We certainly don’t, because we’ve never poured the money and attention into flu that we have COVID. It might be helpful to have reporting that shows all relevant data and lets the educated population (we have around half the adult population in the US with at least an Associates degree, 88% with a high school math education) think for itself. The real worry is that we exhaust the public’s credulity to a point where when a fast moving, truly deadly pandemic hits no one gets worried.

    • MLF-can you please put that as an op-ed to EVERY major newspaper in the country?? And every talking head out there?
      I would also point out that hospitals are now routinely testing for CV-19 when they come in for the procedures that were delayed this spring-and of course, finding lots of asymptomatic, which then becomes a COVID case, not the knee replacement case.
      ” Rather than take a thoughtful, measured and adaptive approach we get good narratives and shaming of anyone who asks a sincere question that might lead other than where the slight of hand leads the herd.” THIS THIS THIS omg from the beginning when questions were raised about the actions being taken (stay the f*** inside business) you wanted “to kill grandma”. Reminds after 911 happened and I happened to say out loud to a group of co-workers that I wondered what the terrorists felt/thinking to think the US deserved this, what did we do to precipitate such a response (I understand a tiny bit more now 🙂 . You would have thought I said I take newborn puppies and routinely boil them alive.

    • @MLF If a “truly deadly pandemic” were to arise, what indication is there the US would handle it any differently? Would we need bodies dropping in the streets for people to accept there is a problem?

    • Response to dirtyjobsguy – (what a great handle! ) Yes I agree this is quite the historic moment of human society demonstrating that we are, after all, crazy monkeys in a panic.
      Regarding the article – I think this is a pretty good round-up of voices covering the basic -need -knows. My opinion is if an article informs and raises questions for me, then that’s a good piece of writing.

  • It is difficult to imagine how the USA is going to recover economically from Covid-19. Socially, it will take time, and there is a divide now that may never be overcome: it is the divide between the ‘Rednecks’ and the Socially responsible & caring. One thing is certain: the USA is now a 21st Century Leper Colony, and will remain that way until both a vaccine and an effective treatment are not only found, but have proven over time to be effective. Until then, America (together with Brazil & a couple of other Countries) will essentially remain isolated from the rest of the World.
    In my opinion, the USA either goes into a total lock-down followed by a well managed staged return to a new normal, or it has to wait until either ‘herd immunity’ (difficult if not impossible, according to your own Professor Willam Hanage of Harvard) is gained or a treatment/vaccine is found. Either way it is going to be a long hard road.

    • “it is the divide between the Rednecks and Socially responsible & caring people” Why is it when someone disagrees they’re called names?
      Not True! please look up “Lock Step” we’re not a leper colony, we’re under attack from the inside! Lock Step was a trial to see if they could make it happen. We’ll be the new Venezuela if Trump does not win.

    • Herd immunity via antibodies was disproved about five months ago when patients in China who had already been ill got ill again. It’s not dying that would worry me, it’s surviving Covid. Given how much damage this virus can do to people with even a mild case (eyes, brain, lungs, heart, liver, kidneys and testicles can all be damaged), would you want to take the chance that you would get it and be OK? What about these post-Covid symptoms that people show, akin to Chronic Fatigue Syndrome? Herd immunity can only be solved by a vaccine and getting a vaccine for a coronavirus that mutates the way this does seems unlikely to me.

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