The Coronavirus is an Evolving Adversary Targeting the Vulnerable
A daily Covid-19 update from Andy Slavitt, former head of the Centers for Medicare and Medicaid Services
I woke up today and tried to understand why am I uneasy with the curve flattening? I called three of the scientists who are most visible, public, and credible to check myself and ask them what we are really learning.
My summary: This virus is an evolutionary powerhouse in ways we are still figuring out. It is embedding itself inside people that can carry it most effectively — young people. And it imbeds itself in people who it gives no motivation to stay in. And it carries its highest viral loads in the earliest days of infection, before people know they have it.
I tried a little exercise in contact tracing today by lightly interviewing someone who was positive for a week before he knew it. He came into contact with dozens of people. I know one of the people he had breakfast with. He went into a conference room with 24 people after that breakfast. That night he visited his elderly mom. I got frustrated at how hard it was to accurately contact trace, so later in the day I called a public health data scientist. He told me it would take five of me to properly track one case over 3 days. A single case.
Would phone based technology help? If 40% of people opted in, and you needed both sides of the equation to opt in, then here’s only a 16% chance of the technology working. So the technology doesn’t solve the problem — you need public health workers.
Of course, there isn’t enough testing to know how much we’re slowing the spread of the virus. Only symptomatic and hospitalized people are being tested. Until the percentage of positive test results declines, we are working through our backlog of sick people.
The virus lives in these unknowing people until they find people to whom the virus is lethal. It attacks hard, and in the worst cases, fools your immune system to start working until it goes into overdrive with a cytokine storm.
But for now we have slowed down the cases enough so that people aren’t dying in hospital hallways. That’s the next devilish thing about the virus. It fools you into thinking you’ve beaten it. Letting up without the right tools means it doesn’t grow, it explodes.
I want to address one other characteristic of the virus that’s most despicable — who it preys on. The weak, the sick, the old, the poor, those with less space. Who it spares: The gated communities, the healthy, the young. It spares those who are the spreaders.
I got a lesson in what’s going on inside jails, prisons, and immigration detention centers today. The reality is no one knows everything, but what we do know is not good. People were not sent to jail to get sick, suffer and die. Our society should not support Dickensian pandemic hotspots. We should pay as much attention to people in prisons as we do to people on cruise ships.
In Cook County jail in Chicago we know that two cases became 250 cases in a couple of weeks. It has since doubled. Plus over 100 staffers (who go back home every night). That’s over 10% of that prison.
2.5 million are behind bars, not counting immigration centers.
While we #StayHome, many are sitting ducks. It’s not hard to imagine tens-of-thousands of cases — or more. Many are high risks, old, with chronic conditions and limited access to care. Even leaving aside the ethical question of why so many non-violent people and people who can’t make bail — and many others are unjustly behind bars — this cannot be ignored. What to do?
All facilities should be required to:
- Report and disclose all cases and ensure proper treatments
- Require sanitary living conditions and proper distancing
- Ensure PPE & proper medical treatment
- Depopulate prisons or transfer prisoners to safer locations when that can’t be done
If someone says, of all the people we have to worry about, people behind bars shouldn’t be a priority, I ask why. Why? At least 2,400 people have died from Covid-19 in prisons. And unlike the rest of us, nothing is changing to make this better. The prisoners are powerless.
Save every life possible. Thanks to the Vera Institute of Justice for helping educate me. Thanks to everyone else who will help bring pressure here.
Homeless shelters are finding 1/3 or more are testing positive for COVID-19. Thanks to Paul Bleicher for passing this along. (He’s a good follow if you like health data geeks.)
Another “hidden” problem is what’s happening to family physicians, mental health professionals, and Medicaid providers — particularly in rural areas. As people stay home and electives are reduced, many will go out of business.
The ask is to set aside somewhere around 30% or the CARES Act funds as a safety net for Medicaid providers. The next bill should add another $100 billion in care provider payments to continue to hit hot spots.
States need to prepare now in a way the country should have been preparing in January and February. Case counts will need to drop but plans must be underway.
The core elements of the plan:
- Begin with manageable number of cases
- Test all symptomatic people
- Contact trace (what I couldn’t do)
- Offer isolation in hotels and wage protection
- Protect vulnerable people (see: nursing homes, prisons to start)
- Build capacity for sudden outbreaks
Details are coming together on these plans in many states. Federal dollars will be required from Congress. And having enough testing won’t happen any time real soon. The best case testing plan will have us at 5 million/week sometime over the summer. But a lower case count and continued #StayHome will help in the meantime. We are going to need to keep case counts much lower and reduce hot spots for that to get us there.
There is my neighboring state to the west, South Dakota. South Dakota has refused to take any measures to protect the public and a meat plant there is now the top hot spot in the country — 644 cases in one plant.
To combine my themes of the day — under-served populations with under-prepared states and under-thinking governors — the Indian reservations in South Dakota and other states are a focus for tomorrow and ahead.
This story is pulled from my daily COVID-19 updates on Twitter
