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Lessons from the pandemic not yet learned

As the coronavirus, once again, surges out of control in the United States, it is safe to say that even those few lessons learned have been cast aside by those who place profits before people. Greed and ignorance, not public health policy, is deciding the fate of tens of thousands in our nation who are likely to die and many times that who will suffer from COVID-19 as we stumble from one surge to another. As other nations succeed, the US continues to fail under incompetent political leadership and a privatized health care system unprepared to handle a domestic epidemic, let alone a global pandemic. This analysis brings together in one place the reasons for this failure and posits remedies the nation could embrace.

Virus control, absent a vaccine, is entirely dependent on the ability of a society to prevent its spread from its point of origin. The new coronavirus, as we have painfully learned, is not an exception. This is the context for the lessons noted here. Scientists studying the transmission of the coronavirus estimate that without any travel or social distancing restrictions, one infected person on average transmits the virus to 2.5 others daily. Roughly estimated, this means if there were 10 cases on day one, in seven days about 10,000 people could be infected.

However, this depends on the individual’s activities. In April, an outbreak in Minnesota occurred in which one person infected 14 others at a house party attended by dozens of people. This outbreak was quickly contained, but had it not, those 14 infected could have increased to hundreds in a few days. In the US, the inability to prevent transmission meant that infections climbed exponentially from 710 confirmed cases on March 14, one day after the national emergency was declared, to 20,000 just 14 days later on March 28.

Social distancing guidelines aim to bring the transmission rate below 1.0, a rate at which any infected persons on average would only infect only one other person per day. At this rate, the virus spread plateaus. Yet, to successfully quarantine the virus, instead of the virus quarantining society, requires pushing the rate down to 0.30, the point at which three infected people on average would only pass the virus on to one other person. Put another way, dramatically reducing the rate of infection entails preventing transmission about 60­–70 percent of the time. At these rates the virus can be managed, perhaps even extinguished over time.

As a nation, we have been reluctant to accept what the virus requires of us in order to put it in check. Deaths and infections, though less than that at the peak, continue at about one thousand deaths and nearly 20,000 new cases daily. At this rate, estimates show at least 100,000 more people will die by Election Day. The director of the Harvard Global Health Institute, Ashish K. Jha, called this stark trajectory “unconscionable.” Jha said, “It’s stunning to me that we have just decided that it’s okay for tens of thousands of Americans to die and we aren’t going to do what we know we can do to prevent those deaths.”

The following lessons speak for themselves. However, the nation’s institutions and political and corporate leaders are still reluctant to heed them. Americans must demand they do their jobs. If, as predicted, the virus persists and reasserts itself during the upcoming flu season fall the nation must be prepared. Americans should accept no excuses.

Lesson number one

For decades political and corporate forces plotted to cut health care budgets, downsize health facilities, and privatize hospitals and health care systems to make a profit. In this pandemic Americans are reaping the deadly consequences of their scheming. The result is a fragmented US corporate health care system, comprised of a myriad of private for profit hospitals and other medical delivery systems, that was unprepared, under-resourced and under-staffed to effectively respond to the virus.

Correcting this will require bringing all major health care providers into the public domain and replacing the inefficient private insurance system with national health insurance – Medicare for All. We need a system where all are insured in a seamless, efficient, service-focused public health care program. This is lesson number one and requires a systemic solution. The critique and lessons that follow are specific to the shortcomings and failures of the past five months.

Delaying quarantine actions was costly

The US was slow to identify the New York City (NYC) area as an epicenter of the infection. The evidence was in sight but was overlooked or ignored. A study released in early April from the Mount Sinai School of Medicine in NYC found that the high traffic volume from Europe and, to a lesser but still significant extent, travel directly between the US and China imported the virus to NYC. As the infection began to rage in Italy by mid-February, typical volumes of passengers were arriving at NY-area airports until the federal government blocked most travel from Europe on March 11. By then the damage had already been done, seeding as many as 10,000 cases before the first person tested positive for COVID-19 in NYC.

Even as deaths mounted in NYC, New York political leaders rejected adopting quarantine-level travel restrictions in and out of the NYC region. Instead, travel continued, and tens of thousands of New Yorkers traveled out of the city, spreading the virus further into the region and nationally.

A recent Yale University genetic epidemiological study confirmed this. Within the US, the coronavirus traveled largely from the NYC region to other parts of the country. A smaller portion traveled from Washington State, where the virus arrived with travelers directly from China, seeding infections in California and Oregon and a few other locales. Surprisingly, the study showed an estimated 50 percent of the California cases resulted from travelers transiting through or arriving from NYC.

Restricting travel in or out of the NYC area, except for essential goods, may still have been effective had a quarantine action been taken when Italy locked down its infected northern cities on March 8, an action restricting the movement of 16 million people.

On March 22, when Gov. Andrew M. Cuomo issued the stay-at-home order for NYC, tens of thousands of passengers had already returned from Italy and Spain and other EU countries. Between these two dates, thousands more were infected in the NYC region and beyond. According to media accounts, few passengers were screened upon arrival. Yet, passengers reported they were only asked if they had been to China, Iran, or South Korea, not France, Italy or Spain.

A Columbia University study showed that had tighter nationwide control been put in place on March 8, fewer than 4,300 would have died by May 3. Instead the tally rose to 21,800. A little arithmetic would lead to conclude, then, that instead of 1,000 dying daily today in May it could be under 100. Restricting unnecessary domestic travel to and from NYC on March 8 in conjunction with enforcing strict quarantine rules and contact tracing for those returning from Europe would also have limited the spread of the virus to uninfected areas. In Minnesota, where I live, 72 percent of the virus cases were transited from the NYC area, while just 15 percent were transmitted from the West Coast. Passengers arriving in Minnesota were screened if they transited from China or Europe but not domestic travelers from New York airports. A costly omission.

A point of origin quarantine model proved effective in Wuhan, China, even once the virus had spread in small numbers to other cities. A modified version of China’s lockdown regime was adopted by France, Spain, and Italy, after other measures failed. By March 1, Italy banned travel in and out of infected areas with the aid of law enforcement and succeeded in minimizing the virus spreading to southern Italy.

The difference between US results by late May and those of Italy is astonishing. In Italy, new daily infections dropped from a high of 6,000 to 1,000 over a period of just one month, an 80 percent decline. In sharp contrast, in mid-May, 115 days into the pandemic, US daily infections fell just 33 percent, from about 30,000 to 20,000. With the virus still not under control states began to open their economies. The result: 50,000 plus cases a day by late June. Until these lessons are heeded disastrous consequences lie ahead.

In recent weeks, new daily cases in Italy, France, and Spain have averaged under 500. The total population of the three countries is 172 million, roughly one-half of the US. A little math shows that if the US had deployed a national coordinated response following these nations’ protocols, new daily US cases would now average just 1,000, not 50,000. What we are witnessing is a national failure. Neglect, denial and unpreparedness has cost tens of thousands of lives, several million to be needlessly infected and incalculable economic suffering. US scientists predicted in March that if the virus is allowed to rule as many as a million may die. Countless others are likely to have scarred lungs and damaged organs after recovering. Learning from these lessons is the only means to avoid such consequences.

Testing, contact tracing and a quarantine regime

Robust contact tracing regimes must be in place, not invented on the fly. Five months after the virus first appeared in the US, we are still implementing a program of testing and isolation. South Korea had such a program in place and quickly implemented it and contained the virus. Those individuals testing positive who could not safely quarantine at home were provided lodging for 14 days. Tracing and health monitoring were done via cell phones. Americans may be reluctant to be monitored like this, but the alternative is to let the virus monitor us. So long as such a regime is not in place, the virus will rule.

Isolating hot spots

In Minnesota and elsewhere, we have heard a lot about hot spots in meat processing plants. In April, a lack of foresight and the capacity to respond caused the virus to travel from a Smithfield plant in Sioux Falls, South Dakota, to the JBS plant in Worthington, Minnesota. Since the plants are only an hour’s drive apart, workers employed at one plant often have relatives and friends working at the other. The virus was identified at the Smithfield plant the second week in April and two weeks later at the Worthington JBS plant. Could this have been avoided or at least minimized? If a quarantine practice were in place, travel between the two areas would have been prohibited immediately after the Smithfield report (even proactively in March). JBS would have been shut down for cleaning and for testing of workers. JBS workers had earlier expressed concern among themselves the virus would spread from Smithfield. They were not heard.

Nursing homes: again a quarantine regime is needed

Testing residents does not solve the problem unless all staff are deemed virus-free and remain virus-free. Once staff leave a COVID-free workplace, they are susceptible to contracting the disease during their daily activities. Extraordinary precautions are the only means to prevent a virus that has a high mortality rate among the elderly. How might this be possible? Medical and all other staff need to be isolated from public interactions. One trip to the grocery store could infect residents the next day. One option is to rent hotel rooms paid for by COVID-allocated funds. Staff who are mothers with infants should be paid to stay at home. Food and other essential needs for quarantined workers should be delivered.

These measures would not only protect residents but also the health care workers’ families and coworkers. Given what we see unfolding daily, it appears that if dramatic steps are not taken, we can expect more infections and a steady stream of deaths arising from nursing homes and assisted living facilities month after month.

Testing failure

Clearly, the US was unprepared to implement a testing regime. Wholly inadequate supplies of fast and reliable testing made effective contact tracing out of reach until recently and even now cannot meet demand. The federal health administrative system and pharmaceutical firms lacked stores of reagents, testing swabs, and equipment. This was inexcusable negligence at the outset and five months later is still causing illness, death, and economic hardship. So long as we cannot test, track, and isolate, we will be forced to stay at home or, as we are now doing, opening the economy facing high rates of infection and deaths.

Public mandate to wear face masks

The failure to immediately mandate wearing face masks in public spaces and for front-line workers clearly increased the spread of the virus. For yet inadequately explained reasons, the Center for Disease Control (CDC) and scientists on the president’s coronavirus task force delayed recommending this preventive measure until April 3rd, weeks after the national emergency was declared. The effectiveness of mask wearing to prevent spread is well established. Asian nations with experience managing epidemics immediately require anyone in public or providing a public service to wear a mask. Why such a logical, well-established preventive measure was not immediately mandated here demands an investigation. Come fall and winter, quality masks for everyone will be needed to prevent the spread of both the coronavirus and new strains of the flu. According to infectious disease control officials in Taiwan, if everyone wears the proper mask, the spread of infection could be reduced by as much as 99 percent.

Are we prepared for fall?

Clearly, not yet. In an interview in May, Dr. Michael Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota, suggested we are lagging behind the virus. “We have to stop promising people everything will be okay, because that’s not going to be the case,” he said. In other words, so long as the virus dictates our future, we are all in jeopardy.

Five months after the pandemic began, production of personal protective equipment (PPE) still lags behind the need. Firms are still unable to provide frontl-ine medical personnel with adequate PPE, unable to produce tens of millions of high-quality masks for public use and unable to produce sufficient materials needed for mass testing. By fall they must be ready. They dare not fail again.

Collective action is the only remedy we have until a vaccine is available. Any institution, business, and governmental entity impeding taking effective action must be forced to measure up to the challenge. State and federal political leaders found wanting and beholden to profiteers, beginning with the current president, need to be swept out of office. If the top management of private health systems and pharmaceutical firms cannot meet the nation’s needs, they should be replaced. Profit is irrelevant; we need performance. We need cooperation between firms, not competition. The lessons described here require collective cooperation and effective leadership. If one or the other falls short, the virus will prevail.

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