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.”

  • This statement pretty much explains the dumpster fire:

    “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. ”

    Essentially the public health community demanded huge sacrifices everywhere to no real purpose and now can’t bring itself to ask for them again, much less expect people to make them, when and where they are really needed. This is not a national crisis, it is a series of local crises and in many places there is no crisis at all. And in many places where there is a crisis it is limited to assisted living facilities.

    There was outrage when Rhode Island prevented people from New York entering the state. But that is exactly what needs to happen. Quarantine communities where the epidemic is spreading, quarantine facilities where the epidemic is spreading and quarantine people who are likely agents of that spreading. That means quarantining hospital staff, nursing home staff and anyone else regularly interacting with infected people.

    Most importantly, we need to end the authoritarian decision making and restore participatory democracy where decisions are publicly discussed before they are made. The idea that there is some group of “experts” with all the answers who will make the best decisions was discredited a long time ago. Engaging a broad range of experience and knowledge in decisions always produces better results. The “emergency” is over. This is our permanent condition for the foreseeable future

  • A dumpster fire is a tightly contained fire in a steel container. Covid 19 is more like a California brush fire, going from 3 acres to 80,000 acres or more in a day or so. Don’t underrate it please.

  • I would love to be able to get a hold on the in home tests. Could you please make the info available. Thanks so much

  • This was a good summary. It is a shame we have no leadership and many “believe” it is a hoax. Even those that catch the virus think it is an act of God, not the virus that is making them sick. I’m over 80 and have lung cancer. When I see so many people without masks I have to wonder, do they want to commit suicide? Or did they want to kill me.

  • Here is a novel idea for the novel virus. Treat it the same way we have treated the flu and other viruses. Give us the facts (not fear mongering 24 hour news reports, false data, misinformation, and unsubtantiated advice from “medical experts” that have something to gain from perpetuating a crisis) and let people use the brains God gave them to protect themselves and their loved ones. The more I learn about this virus from credible sources and personal experience, this virus is not much different than the flu, there is little evidence if any that it is transmitted by asymptomatic people, our medical system is equipped to deal with the rare severe cases, the “new cases” are trumped up to reflect anyone that has taken a test (positive results or not) and reflect increased testing, the death rates are trumped up to include anyone that came to the hospital with any virus symptom whether they tested positive or not and whether they died from the virus or not, and there are safe, effective and inexpensive treatments that have been identified for the virus but are being ignored. In the meantime, the world economy and people’s lives are being destroyed in countless ways as a result of the draconian measures to combat a hyped up virus that is not living up to its billing. This is not the Black Plague. Let’s stop the mania and stop living in fear.

    • As a physician in a hospital whose ICUs and wards are full to the brim, all I can say is we are tired. Everyone is stretched thin. There isn’t enough equipment. We ran out of IV poles and pumps yesterday! We’ve definitely run out of high-flow nasal canulas (oxygen equipment for very sick people) and come down to our last ventilator. There was a night we almost ran out of blood (because blood donations are down). There is nothing more demoralizing that watching increasingly young and health individuals die of a preventable disease, while watching the general public ignore general precautions. Having the huge hospital burden affect the care of other people who don’t have COVID but are unfortunate to be sick at the same time. I’m pretty tired of writing death certificates and condolence cards. I have concluded that nothing but getting sick or having people close to you die will convince Americans and their leaders to make better policy, and I actually am not sure that this even will change things. Anybody who tells you “Everything’s great in the hospital system” is out of their mind. We can’t keep this up. I’m tired. I’m scared. I don’t want you to be sick, prematurely disabled with a stroke or permanent lung damage, or to have your loved ones die. I don’t want to be the one who tells the last child in a family that, on the day he buries his mother and after he buried his brother, that he has to let his father go as well who is brain dead on a ventilator (yes, we are getting whole families hospitalized). If the USA as a nation refuses to learn from science or others’ mistakes, then we will get sick and die. And we are.

    • You obviously don’t live in the same world that I do, or have so many blinders on that you’re incapable of rational analysis. At least half of your statements are just wrong, and I can’t agree with your conclusions from the rest. In particular, I’ll bet Texas & Florida & California would like to hear about the “safe, effective & inexpensive treatments ” you think are out there.

  • Terrific round-up of information on Covid-19 from many great sources. I am very encouraged to hear from so many researchers and others determined to get a sane and lucid message out to others.
    The at-home self test for Covid is such an obvious effective tool – I hope this idea bears out soon.
    Thank you

  • Thank you for this but I agree with the comment below. If links could be provided to the testing information and other potential initiatives, that would be extremely helpful. Any articles on COVID19 really need additional resources at this point since we are on our own in this crisis with either no guidance or utterly confusing, vague yet panic-inducing overreach from supposed leaders. Thank you.

  • Ms. Branswell, could you cite your source(s) on the availability of at-home testing technology? All I can find is at-home *collection* kits at $100-$150+, single-use for mailing in to a lab. I’d be interested to know if/how the state of the art is actually far advanced beyond this.

  • Personal Data Monitoring & Prediction: Rather than just relying on after the fact, and often politicized, public CV-19 guidance I started informally monitoring the local percentages of people wearing masks and social distancing in my twice weekly shopping excursions (currently with a mask and gloves). Before local reopenings started I observed about 80% following the guidelines as the state daily infection rates declined below 100.

    Then as the state started reopening (disregarding previously data based guidelines, and without emphasizing that people should continue safe practices) percentage of mask wearers suddenly dropped to about 20% and Ithought “Oh-oh!” Then the daily infections climbed steadily from 100 to 2oo in about a week, then 300/400/500, and recently topped in the 700-800 range.

    Two weeks after the reopening the state tightened the rules a bit and really started promoting and emphasizing the need to continue using masks and doing social distancing. That was 2-3 weeks ago and my recent observations are showing 90+% compliance. Over the past week the daily infection rates have steadily subsided back down too around 400. If my thesis regarding the “observed percentage of mask wearers” is correct the daily infection rates should be shrinking back down below 100 within two weeks – IF the public continues to follow the CDC guide on masks and distancing (and mass gatherings).

    So (if I am right), almost anyone should be able to predict (about 2-3 weeks ahead) the local spread or decline of Covid-19 during the pandemic simply by personally observing the percentage of people that are following science based guidelines to prevent the virus spread (otherwise known as acting sane and being responsible).

    I’d like to see if other have tried local personal observing/data collection and what their results are. I find it a bit amazing that I appear know what what is going to happen a week or two before the politicians and decision makers do.

    Stay aware and stay healthy!

    • Why is a “dumpster fire” used as a metaphor for something really bad? Isn’t a fire that’s stopped from spreading by a self-container metal box a lot less scary than a fire that’s burning multiple buildings in a dense neighborhood or a raging hospital fire? Dumpster fire seems pretty tame to me.

    • Lovely use of practical observation about your local neighborhood. Thank you for this insight.

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