Lessons from covid19 – Part 3: Where are we now? What’s next?

As the country starts to slowly evolve from “lockdowns” and “stay at home,” there is understandable fear that the relaxation of restrictions will result in a rebound effect. But unless one thinks that the entire population except essential workers can spend the next several months, rest of the year, next year, or longer isolated at home, there has to come a point when we smartly evolve out of the lockdown. Even some staunch proponents of staying at home, including Dr. Anthony Fauci, are starting to agree. The way we see it, there are three equally compelling and equally difficult tasks our country must accomplish going forward (and frankly should have been addressing better from the start of this pandemic):  

1. Care for covid patients
2. Care for the non-covid patients 
3. Care for the economy 

Policy makers cannot isolate their decisions to only one of these tasks without considering the other two. One does not rise above the other, and while the pace to tackle each might vary a bit, we have to deal with all three, just as in any war multiple tasks must be accomplished simultaneously. And just like in a war, every citizen has a role to play so that the country can accomplish all three tasks. We have prioritized (1) which is appropriate in the short term. We are working on tests, vaccines, social distancing, anti-viral development, we know density plays a major role (cities, nursing homes, poverty), and that the elderly and those with some chronic conditions are more vulnerable. But in the intermediate term, where we find ourselves now, if we do not address (2) and (3), the ongoing situation will make our public health efforts (which have been floundering in recent years with deaths of despair, joblessness, and poverty) even worse. The country has to deal with all three tasks, so we might as well quit fighting to prioritize one task over the others and get on with all three.

So how should the US move forward? It is clear that all states are gradually re-opening their economies. It is possible that those steps could lead to increased deaths. But no strategy is without deaths – and both covid and non-covid deaths must be considered. Given the past experience with flu epidemics, it is also likely that a second wave will hit at some point. To us the following would be reasonable steps for the US to follow going forward. 

First, it probably goes without special emphasis that until we are through this pandemic we need: 

• More testing and tracing
• Maintaining social distancing
• Masks for all in public when proper social distancing is not possible 
• Ensuring there is an adequate supply of Personal Protective Equipment (PPE) for all essential workers, those in businesses essential for our infrastructure – e.g. healthcare, first responders, electric power, water, food processing, etc.

Assuming we will have some type of second wave, we would recommend the following: 

Protect the most vulnerable, but do not re-instate blanket stay-at-home orders.

Instead, follow what the UK’s Imperial College actually felt was the best approach in their initial covid19 report, namely, do stay-at-home only for the segment of the population most at risk – those over age 70 – while letting the working age, lower risk population actually go to work. Many reports and the CDC covid19 tracker have shown that covid19 deaths are concentrated in the elderly population and individuals with significant underlying medical problems. In fact, CDC data as of 5/13/20 showed that ~80% of covid deaths are over age 65 and ~59% over age 75. In other words, the majority of deaths are not just over age 65, but over age 80. A preliminary analysis of the correlation between lockdown severity and excess deaths in Europe suggests that, “…while restrictions on movement were seen as a necessary tool to halt the spread of the virus, when and how they were wielded was more important than their severity.”

Take special steps to ensure the safety of patients and workers in nursing homes – that small subset of our population absolutely at most risk. The World Health Organization has reported that half of the deaths in Europe are coming from nursing homes. And while in the US the nursing home number currently stands at 33% of total deaths, the percentages vary significantly by location, with Minnesota and West Virginia reporting that as many as 80% of covid deaths in each state were in nursing homes. Specific steps would include restricting visitors, increasing testing and PPE access for staff and patients, as well as additional staff training to manage the risk and spread of infection. Ideally, hospitalized patients should be allowed readmission to nursing homes only if they have a positive blood covid antibody test. If only a diagnostic test is available, the patients should be discharged to a nursing facility only if there is a separate, designated covid isolation area or if the nursing facility is a covid designated facility.  

The stay-at-home orders, as previously implemented, have significant implications for both the health AND livelihood of millions of people who do not fall into the “covid” category. It appears that to fight covid, we have gone further in shutting down the economy than happened with the most recent pandemics (we did not have data back to 1918). The chart below provides a perspective on previous pandemics with unemployment and GDP growth factored in as well: 

	Death per million	Unemployment	GDP growth
1918/19 Spanish Flu	6,553	N/A	N/A
1957 H1N1	674	5.2%	+2.1%
1968 H1N2	497	3.4%	+4.9%
2020 Covid 19*	515 (303 – 727)	11.5%	-5.6% (CBO Est)

Below are some of the impacts on the lives of people affected by the repercussions of our policies on the economy. Columbia University has estimated that 21M people will be added to poverty. The number of people relying on soup kitchens and food banks has already increased significantly. And as a recent The Hill editorial highlights,

“Mass layoffs during recessions increase both the short-term and long-term age-specific mortality risks of laid-off workers. For middle-aged male workers, mortality rates in the year after being laid off are 50 percent to 100 percent higher than they would have been otherwise. The effect of poverty on age-specific mortality is brutal. In the United States, the poor die 10 to 15 years earlier than the wealthy.”  

While the CBO has estimated year end unemployment at 11.5%, others have estimated it could reach or exceed the peak unemployment seen in the Great Depression of 25%. In addition to health impacts of pushing people into unemployment and poverty shown above, there are also the issues of despair, depression, and other mental illness that will play out. Many of the laid off workers aren’t likely to get their jobs back. “Our best guess is something like … 40% (of employment reduction) is going to be permanent,” said Nicholas Bloom, an economics professor at Stanford University.”

Moreover, strictly enforced “stay at home” policies lead to isolation – bad enough for multi-person households, but especially hard for single person households. As highlighted in a recent The New Yorker article, 28% of households, or 35.7 million people in the US live alone and this isolation has health implications: 

“Prolonged loneliness can even increase mortality rates. In 2015, Julianne Holt-Lunstad, a neuroscientist and psychologist, published an analysis of seventy studies, involving 3.4 million people, examining the impact of social isolation, loneliness, and living alone. The results were notable in light of today’s pandemic. The review found that…social isolation led to an increased rate of mortality of twenty-nine per cent.” 

Perhaps not surprisingly, the Substance Abuse and Mental Health Services Administration’s Disaster Distress Helpline saw a ~900% increase in call volume in March 2020 compared with March 2019.

This need for policy decisions to consider implications beyond the immediate threat of covid19, is starting to get recognized by some public health experts: “Dr. George Rutherford, head of infectious disease and global epidemiology at UCSF, points out the balancing act decision makers must perform. Bad economies are as hurtful to health as viruses.”

Do not re-institute policies that emptied out our medical centers of almost all but covid patients.  

Even in the worst hit (areas) stateslike New York and New Jersey, the share of hospital beds occupied by covid19 patients maxed out at ~40%, and in the vast majority of states never rose above the teens or even single digits. Instead, each location should look at how much covid patient capacity was used in the first round and determine how best to handle a second wave. It is of interest that the state of New York is suggesting that going forward hospitals need to maintain 30% of overall and ICU beds unoccupied.

The mandated cancellation of all elective procedures had a devastating impact on the healthcare delivery system, not only from a financial standpoint, but most importantly in its ability to care for the non-covid population. The University of Michigan has estimated there are 10,000 diseases impacting humans. The UK’s NHS has a list of more than 325 common diseases (including conditions like cancer, stroke, heart disease, MS, diabetes, etc.). And yet, all these other diseases, many extremely serious, seem to have been forgotten. Because of the unknown magnitude of resource use that might be required for covid 19, all of these diseases took a back seat (or for many, a couple months with no seat at all). Emptying out hospitals may have been the right strategy for some locations, but to date it appears to not be warranted in many locales. And there are repercussions to the patients that are put off. Some providers worry that, “…the toll on non-Covid patients will be much greater than Covid deaths.”

Moreover, many patients are delaying seeking care because a) they have been encouraged to stay home to protect healthcare workers and flatten the curve or b) they are scared of being exposed to covid in the healthcare setting. Data from various states are beginning to suggest that a “silent epidemic” of non-covid conditions is already in progress. As stated by Dr. Reginald Eadie, CEO of Trinity Health of New England, “Do the significant decreases in hospitalizations for these five serious illnesses [heart attack, heart failure, stroke, appendicitis, gallbladder disease] and the increase in at-home deaths suggest another public health crisis is on the way?” A recent letter to president Trump, signed by hundreds of physicians, outlines the many concerns about the growing negative consequences of the shutdowns on millions of non-covid19 patients. The non-covid patients in the US got short shrift in the first go around with covid. They should not get the same in a second wave.

And the situation is likely not unique to the US. A study by Imperial College, John Hopkins and others indicated that deaths from TB worldwide will likely be increased by 1.4 million people because of the covid mitigation policies. As reported by CNBC, 

“This situation makes me sick, because (it) is totally avoidable,” Lucica Ditiu, executive director of the Stop TB Partnership, said via email. “We just need to keep in mind that TB, as well as other diseases, keep affecting and killing people every single day, not just Covid-19.” 

In summary, leaders making decisions about the future of our country need to ensure that policies take into account all aspects of this national problem – impact on covid patients; impact on non-covid patients; impact on the long-term health and wellbeing of the population from damage to the economy. One does not rise above the other, we have to find a way to deal with all three simultaneously.