Beating Coronavirus Also Makes Prevention Behaviors Harder to Sustain

A daily Covid-19 update from Andy Slavitt, former head of the Centers for Medicare and Medicaid Services

Andy Slavitt
Medium Coronavirus Blog


Jane Barlow/PA Images via Getty Images

Today I talked with scientists and innovators to try and get as good a projection of the future that I could. It is flawed by definition, no one knows the future. I also heard some about the present response: the Congressional bill, plans from the Trump administration, and hospital realities.

Let’s start with a piece of positive news. Scientists see rapid testing/intelligence, a vaccine, and herd immunity as the combination we need to return to complete normalcy. Here’s my summary from a bunch of voices: We go through a period of shock, lack of context, and occasional disbelief. Many follow instructions to #StayHome. A number of people don’t. We’re not trying to reduce the spread just slow it on behalf of the frontline health workers.

During this period we see horrific numbers on TV and horrific images of hospital scenes. It’s tough to watch. But it may not be happening in your city/town. And this phenomenon is both good news and a problem.

This bit is newsworthy: I took a look at real time data today of the fever levels reported in two areas; San Francisco, CA where there are strict controls and an area of Florida where people are completely mixing it up. It’s real time data and it makes a comparison to normal fever levels.

Here is the good news. It appears that the measures in San Francisco are working. San Francisco put in place strict #StayHome measure. Miami-Dade county in Florida lagged. Good job Bay Area. I know it’s hard.

Here’s the hard part. It’s completely re-enforcing. Usually we like to see a visual of our progress. People in San Francisco are seeing less of a crush on their healthcare systems and as a result and are wondering, “why are we doing this?” That makes it harder to sustain. If they could teleport to New York, they would know why.

So behaviors that prevent spread become hard to sustain. It would be different if we had enough testing. If we knew we were infectious, we would stay in. People experience five asymptomatic days on average when we get Covid-19. As a result of all of this, people will be inclined to break the social isolation.

Something I learned today was how much the virus hates ultraviolet light. So R-naught (R0) goes down by an estimated .5%. (So from 2.3 to 1.8 for example.) R-naught is the number of people each infected person infects. It is a critical factor in how fast the disease spreads. 80% of people or so who test positive don’t know where they caught it. R-naught needs to be reduced below 1 for the virus to begin to die.

So this summer, as some cities get past the bad part, as R-naught goes down and people don’t believe or don’t see a problem, they feel the hardship and there will be a clamoring for normalcy.

I believe there will be another reason — the election. No matter what the scientist tell him, Trump will fixate on any good news and declare things over. Go back to work! Play baseball! Invest in stocks! Scientists I mentioned this to, were horrified.

If this happens with no access to testing, it would be a very bad thing in their view. So, one idea instead, is let businesses open if they install non-contact thermometers or require temperatures be taken prior to entry, while limiting capacity.

The next phase, likely in the Fall, many believe that like the flu, Covid-19 will be seasonal and as things cool down and R-naught skyrockets with the end of summer and some schools open, it could come back, possibly worse.

But here’s the thing: We aren’t avoiding the spread. We’re trying to slow it down. Both to avoid the crush on hospitals and healthcare services/workers, and to create solutions for testing, prophylaxis, and therapies while we advance the vaccine. So we could have many more tools in the future, in addition to social protocols.

Next phase: We have a lot of cases, but by this time if we’re thinking ahead, we’ve got great PPE (personal protective equipment) manufacturing, more hospital capacity, an immune population, more ventilators, and we are beginning to know how to deal. But my guess is we’re probably also a little numb.

A strange argument begins to dominate (it’s already started). That treating Covid-19 is actually worse than not. That the economic consequences aren’t worth it. That 60k people die from the flu every year and we can’t shut everything down. People in the White House say right now the Larry Kudlow crowd is driving this argument. I’ve heard the health people are pretty frustrated because the immediate issue is overwhelming the hospital system.

By early Spring 2021 we know whether we have a vaccine that works. We hopefully have nationwide testing and a system for identifying people with immunity — I’ve heard nothing to worry me that we won’t — and it becomes widely available Fall 2021.

The combination of immune people & people who have the vaccine climbs to 80%. At that point R-naught could be as high as 5, but 4 of those people wouldn’t get infected. Awesome! But what then? We would have “high Covid-19” seasons ongoing (as someone on a call said, like High Smog Days) when older or at-risk people stay inside. We may have masks and testing sites, and fever camps as well.

Viruses hate vaccines and so they mutate, but at this point we’ve got a thousand Jonas Salk’s searching for inoculations and creating vaccines. In a good world, we have a President & Congress who invest in public health — the CDC (Center for Disease Control and Prevention) and the NIH (National Institutes of Health) and health care coverage. In the other world, we don’t, and have to spend $5 trillion on the next disaster, plus an economic depression, job loss, and death.

Speaking of Trump, his tweet today on how you can mix two drugs and they will work, was worse than irresponsible. It was destructive. Hospital CEOs called to tell me they have long lines asking for these drugs. Even if they worked, they are in ridiculously short supply. Tump sees popularity bumps as indicators he’s doing the right thing. War time presidents can’t be snake oil salesmen.

I’ll share more on the Congressional state of play tomorrow. Speaker Pelosi, Senator Schumer, and Senator McConnell are hashing things out. McConnell is checking in with the White House. Will give more when I get it.