From Barry Rotman, MD

What happens after a shelter in place?
Barry Rotman, MD

Barry Rotman, MD

April 24, 2020
Forty years ago (wow!) when I took a macroeconomics course, we learned about the classic “guns vs. butter” trade-off when governments chose between defense or consumer spending. Governments today face the much higher-stakes “lives vs. dollars” conundrum as they navigate the coronavirus pandemic. Our current shelter-in-place policy reflects maximum emphasis on saving lives. In Contra…

Forty years ago (wow!) when I took a macroeconomics course, we learned about the classic “guns vs. butter” trade-off when governments chose between defense or consumer spending. Governments today face the much higher-stakes “lives vs. dollars” conundrum as they navigate the coronavirus pandemic.

Our current shelter-in-place policy reflects maximum emphasis on saving lives. In Contra Costa County, we have done a great job: As of 4/22/2020, there have only been 22 COVID 19 deaths in our county of more than 1.1 million. We have successfully “flattened the curve.” However, two recent antibody studies in Santa Clara and Los Angeles Counties show that only an estimated 3% of the population in these urban areas have had COVID 19. That is, 97% of us are still at risk for the disease, far from the 50% figure needed to benefit from herd immunity. Eventually, we will need to move away from shelter-in-place to a policy of greater economic activity. Given the volume and complexity of news coverage on this topic, I present a deeper dive into some of the fundamental concepts underlying the policies under discussion.

In order to understand how governments navigate this transition, one needs a familiarity with the epidemiological concepts of “containment” and “mitigation” as well as the vital role of testing.

Containment denotes a strategy of identifying infected individuals and their contacts with the goal of quarantining them to prevent the spread of illness. Countries such as South Korea and Taiwan have implemented very successful containment efforts preventing high death tolls. Crucial to their efforts has been the ability to rapidly and accurately test thousands of people. If infected individuals are quarantined, the remainder of society can remain open. In addition to testing, there needs to be the ability to rigorously enforce quarantine. Taiwan has a system to trace patients by their smartphone GPS coordinates. Movement out of quarantine or even turning your phone off can result in a stiff fine. Aggressive testing and quarantining are two key policies in an array of strategies that have allowed South Korea and Taiwan to avoid society-wide lock downs.

Unfortunately, the United States never had enough testing capability for a containment strategy. Recent population antibody studies suggest that our policy of RT-PCR testing may have identified only 2-4 out of every HUNDRED patients infected with COVID 19. Given our meager ability to identify infected individuals, it was impossible to implement a successful quarantine strategy. Instead, we had to resort to a mitigation policy, which I would describe as the epidemiology equivalent of “abandoning ship.”  We have been forced to retreat from communal society to shelter alone, in our own homes, with the objectives of protecting the most vulnerable from infection and curtailing the infection by reducing contact among individuals. This is the most blunt (and expensive) of policy options, but it did prevent the infection from spreading unchecked and potentially killing millions.

Fortunately, many regions of the United States have succeeded in reducing the spread in COVID 19. Even the hardest hit areas such as New York City have seen declines in death rates. The need for more testing has become a political mantra, with assessment of adequacy breaking down along political divisions. If we have enough testing capability, we have the POTENTIAL to turn our current mitigation strategy into a containment strategy. Here is how:  With enough time and effectiveness, social distancing might be able to drastically lower the number of new infections, essentially creating a “do over” situation. If we have much fewer new cases and we can successfully test and identify them, we have the potential to approach the challenge again and implement a containment strategy.

There are many sequential “what ifs” in this perhaps overly optimistic scenario:

(1) As a society, can we hold onto shelter-in-place long enough to drive down infection rates? Each day brings more economic fallout and political pressure to open society.

(2) Can we test enough people to identify most new infections? Direct government involvement in testing has been an unmitigated disaster. Fortunately, commercial, and academic labs have generated a plethora of options. However, current challenges include assessing accuracy, fixing supply shortages, and scaling up production capacity–all at breakneck speed.

(3) Can we successfully quarantine people? South Korea and Taiwan have cultural values very different from ours, in terms of individual rights vs. the collective good. Will we agree to electronic surveillance or required placement in treatment centers for the duration of illness? There are many hurdles moving forward, but the status quo is untenable.

In the coming weeks, political leaders will make some of the most momentous decisions for our society since WWII as they struggle to balance safety and prosperity.

I hope to have provided a framework for better understanding the process. As always, I welcome your questions and comments.

Barry Rotman, MD

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