COVID19: A Path Forward
COVID-19 presents the most pressing infectious disease challenge we have faced in over a century. If predictions are correct, this virus will exact an enormous toll in terms of death, hospitalization, and disruption. It will stress hospitals, panic populations, and alter life. Healthcare providers will not only be infected but be faced with unfathomable decisions in a setting in which standards of care may be altered.
It did not have to be this way.
In about 1997, DA Henderson — the man who eradicated smallpox– warned of the looming threat of pandemics and infectious disease emergencies as he founded a think tank dedicated to preparing the country. In the years since, the anthrax attacks, SARS, avian influenza, the 2009 H1N1 influenza pandemic, Ebola, and Zika confirmed this threat, and gave us the opportunity to learn more about it. Pandemic preparedness professionals, like myself, constantly wrote, spoke, and conducted exercises to help prepare the country, identify shortcomings, and advise policymakers. In 2018, I specifically, wrote about the pandemic potential of respiratory viruses and the need for diagnostic testing. Indeed, when the story of this pandemic is written, the handicapping of our response by inadequate diagnostic capacity will be a major theme.
Such advice, delivered over the span of decades, was not properly heeded and today, we live in the world created by inaction, short-range thinking, and a continual cycle of panic and neglect, while our reports gather dust in desk drawers.
The unprecedented challenge we face with COVID-19 is the predictable result of years of neglect when the biosecurity budget was less than that for military marching bands.
The results of that neglect are manifest today.
If we were to design a scenario in which a disease is allowed to spread rampantly throughout the country what better way would there be than to first deny its significance, create restrictive testing criteria that cements the disease as exclusively travel-related, ignores the need to test and isolate those with mild (yet communicable) cases, and delimits the ability of laboratories to develop their own testing. It is almost as if we extended hospitality to COVID-19. The events of this pandemic have played out like a train heading to imminent disaster.
Now, because of perennial inaction, we face the specter of hospitals in crisis, rationing of care, deficiencies of personal protective equipment, and possibly hundreds of thousands of death.
Driven by panic at a crisis they ignored for too long, policy makers are considering imposing mandatory prolonged social distancing measures, the cascading effects of which may be worse than those of the virus itself. Economic shutdowns, travel bans, border closures, rising unemployment, shortages of vital goods — all predicted in numerous tabletop exercises — are what we now face.
Plans of prolonged, enforced confinement aimed at preserving life at any cost are premised on a misunderstanding of human life and what makes it worth living. When discussing treatment options with a patient, I often invoke the concept of “quality of life”. Patients regularly choose to take on some risk to their longevity in order to preserve or enhance their quality of life. Individual preferences and shared decision-making with physicians guide medical decision making and also should apply to each individual’s decision regarding the degree of social distancing that is appropriate for them.
A degraded quality of life, particularly over time, itself generates its own risks of death. If the lockdown is prolonged, we can expect increases in deaths from cancer, cardiovascular disease, stroke, mental illness, and substance abuse. How many cancers will metastasize while colonoscopies or biopsies deemed “elective” will be postponed?
Quality of life consists largely in the ability to engage in the activities that make up our lives, and central to these activities is work. Most of us need to work to support ourselves, and many people, including myself, derive meaning from their work. Moreover, humans, as a species, survive by productive work. Jobs cannot be easily parsed into “life-sustaining” and “non-life-sustaining” enterprises. All work consists in the creating of something we need to sustain human life physically and psychologically. Some of these needs are more acute than others, but all contribute to our ability and will to live. Stopping people from working is like depriving a limb of blood flow. Though action is sometimes necessary in an emergency, irreparable and irreversible harm will occur if it is prolonged. A prolonged freeze of the economy — even in the face of a deadly pandemic — will cause a long-term damage far greater than any purported benefit.
If a prolonged, enforced retreat from life is not the right way to fight this disease, what is? Until a vaccine is developed, I recommend the following five measures.
1. Voluntary social distancing with cocooning: It is necessary — and critical for high risk groups — to be vigilant about minimizing the risk of viral spread. Each individual and institution should take specific actions, consistent with their own hierarchy of values, to not be an unwitting host to a virus that may damage themselves or others. Specific clusters of vulnerable populations such as nursing homes should be cocooned from everyday life to greatly minimize their chances of exposure. When social distancing is mandated by law it should exist for as short as possible of a time frame and to allow as much flexibility to individuals as possible.
2. Hospital preparedness: To meet the demand of the expected surge of patients, resources should be directed to expand hospital capacity. While many of these activities will take months to scale-up, the pandemic will likely continue for a year or more. Some activities that can be started now can be expected to have an impact in the days or weeks, others will benefit us months from now. Among the measures the federal government with state, local, and private partners should begin immediately are constructing new hospitals, reopening recently closed hospitals, and using alternative care sites. The federal government, again in collaboration with private partners, must also quickly scale up the production of mechanical ventilators and personal protective equipment (PPE) for healthcare workers.
3. Diagnostics: To allocate scarce medical resources and to make informed decisions about social distancing in different communities, we need to do dramatically more diagnostic testing across the country. Towards this end, we should stop requiring all tests to go through comprehensive testing to be considered ‘CLIA-waived’ and suitable for use at the point-of-care. If a test can be reasonably performed at the point-of-care, it should be granted that status. There also exists, at this time, home diagnostic testing technology for influenza that can provide results for patients at the point-of-care in their own home. Though not yet approved, it can be adapted to test for the novel coronavirus and quickly made available. Such testing will help individuals infected with the virus to know their status and self-isolate. Such home diagnostic technology can also provide knowledge of community disease prevalence. Performance of serological testing to determine extent of infection and the level of immunity in a community is also a priority activity.
4. Healthcare worker augmentation: The potential shortage of healthcare workers can be partially alleviated by immediately expanding the scope of practice of nurse practitioners, nurse anesthetists, physician assistants, paramedics, pharmacists, psychologists, and emergency medical technicians. Currently, a patchwork of disparate regulations occurs in states and it is long since past due that these medical professionals be able to practice to the full extent of their training and ability. It is also important for states to extend healthcare worker license reciprocity across all 50 state lines.
5. Right to Try: As new medical countermeasures are developed for COVID19, it is crucial that they be studied in rigorous randomized control trials to determine their efficacy and safety. However, individuals’ right to try such drugs or vaccines and physicians’ right to prescribe them prior to full approval should not be abridged. “Right to try” should immediately be expanded to COVID19-related products.
The days ahead will be difficult for every American and especially so for healthcare workers. However, the answer to this challenge is not to shrink back in panic but to take decisive action to fight the pandemic, while continuing to lead our lives. In the past infectious diseases claimed more lives per capita than are projected to be at risk from this pandemic, but humans rarely responded by retreating from activity. In the years when smallpox ravaged the planet and rubella crippled babies, humans went to the moon.
