How long can we keep this up?
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Last week, a friend asked me for advice on how to get to the doctor. She’s 8 months pregnant and lives in New York City, and she had an obstetric appointment the next day. She wanted to know which I thought was safer, taking the subway or a Lyft.
I told her that I thought the most important thing was for her to wash her hands as soon as she got to her doctor’s office, and that either was probably OK, but if she wanted to have maximum control over her environment, go for the Lyft. I thought through the intricacies of each scenario in my head: On the subway, it might be easier not to touch anything with her hands, but in a Lyft, there would be fewer people and fewer surprises. In the end, what I really wanted was just for her to feel like she could go to a prenatal appointment safely, whichever way she chose.
My friend’s decision about how to get to the doctor is one small example of a larger problem that has surfaced however many days into this pandemic we are. For the most part, people have absorbed that it is critical we all do the right thing. But what is the right thing? And how long do we have to do it for?
This is a deceptively tricky question. It’s a question that starts small, like my friend’s question, and then expands. The first-order question around this virus is obvious: How do I keep from getting it? And if I get it, how do I keep from spreading it to someone’s grandmother or spouse? We are all grappling with the fact that our personal health is more connected to everyone else’s health than we previously realized.
“Stay at home” is, for now, the agreed-upon answer. But “stay at home,” as we know, has costs, for each of us and for society. And it’s not always possible, or the best option. After I answered my friend’s question, I also forwarded her a recent newsletter by Emily Oster that argued that even though hospitals might be overwhelmed by highly contagious coronavirus patients, deciding to give birth at home is still not a safer option—advice Oster stood by on Monday even after some New York hospitals announced they would no longer allow partners to be present during birth. “This situation is awful,” Oster added. There are no easy decisions.
Another version of this nesting doll of conundrums was the debate over closing schools: Is closing school really the right thing, when so many children rely on their school for food and, to some extent, stability and safety (a sad reality)? Are we trading one ill for another, and how do we weigh them against each other? Also, what happens if kids sent home from school, potentially preloaded with germs, infect the grandparents who in some cases are now taking care of them while the parents have to work? How can we be sure we’re not inadvertently hurting more people than we protect, when we are taking these actions to protect people?
The same sorts of questions came up as state after state issued edicts closing bars and restaurants, and those bars and restaurants started unprecedented mass layoffs. The economic disruption that has resulted from the protective measures we are taking is enormous, and it will have its own set of devastating consequences, including lives ruined in other ways, if not by a respiratory disease. The president raised this ineloquently on Sunday night, with the economy in mind more than human lives. But the question is the same: Are we absolutely sure we are doing the right thing?
In other words, trying to stop the spread of the virus now to avoid one set of terrible outcomes is causing another set of terrible outcomes. Rarely in one’s life is it so clear that even if you make every choice perfectly, you will at most help us stay on the least worst path.
The reason we are taking the drastic measure of staying home is, as we all now know, because we are trying to “flatten the curve” (the current ubiquity of this phrase is an incredible success story of a complex idea boiled down into simple messaging). The effort is universally supported by public health officials, and, to be clear, is one I believe we should follow. We’ve been told that the price of failing to slow the spread of the virus will be a health care system so overwhelmed that many people will not be able to get treatment, and mortality will shoot up to perhaps unimaginable levels, as is happening in Italy. Certainly preventing an unmitigated scenario of 2.2 million deaths is worth the price of a recession and the extra burden on struggling families.
But even as “flatten the curve” has become accepted shorthand, the details remain opaque. Where we are on the curve? How flat is the right amount of flattening? Where is the line where hospitals become overwhelmed, at what speed are we moving along the X-axis, and have we lowered the number of cases enough? In other words, are we absolutely sure the dramatic actions we’re taking will result in less death, overall?
Professor John P.A. Ioannidis of Stanford University—by reputation one of the smartest people in fields ranging from epidemiology to biomedical data science—published a somewhat controversial piece in Stat News last week that warned of the possibility that our best efforts might end up backfiring:
If the health system does become overwhelmed, the majority of the extra deaths may not be due to coronavirus but to other common diseases and conditions such as heart attacks, strokes, trauma, bleeding, and the like that are not adequately treated. If the level of the epidemic does overwhelm the health system and extreme measures have only modest effectiveness, then flattening the curve may make things worse: Instead of being overwhelmed during a short, acute phase, the health system will remain overwhelmed for a more protracted period.
Ioannidis’ piece got some pushback by public health experts who worried that his questioning might make people less likely to follow instructions to self-isolate and stay indoors. But even his critics seem to agree that it is absolutely critical for us to have better data.
We are currently quite lacking in data and sorely in need of it. We need to know many more things about the virus and what it does to the human body, including who it affects and how to treat it. We need better testing to figure out how many people in the United States have it, even as the people on the front lines are realizing that they themselves have to shift their efforts away from containment approaches and toward treatment and mitigation of spread.
We also need data on how our current approach is working and data on what the costs of this approach really are. We need to know how much our current version of social distancing, with everyone still going to the grocery store every few days, is affecting the rate of spread. We need to figure out how much people being stuck at home might lead to an uptick in domestic abuse or suicide. We need to know if more women are giving birth at home, and if more women are being forced to carry pregnancies that they don’t want as their right to abortion is interrupted. We need to know how the people who are laid off from their jobs are getting food, and if they are still willing to access health care when the financial cost of doing so might be very uncertain. We are all engaged in an enormous, high-stakes nationwide experiment right now, and we need all of this data to answer the question: Are we doing the right thing?
And still, the questions remain: How long can we really do this for? What else could we do? What should we do next?
Academic physicians Aaron Carroll and Ashish Jha have a piece in the Atlantic in which they consider the various possible scenarios in front of us. The extremes are helpfully familiar—on one side, do nothing, which we’re already doing better than; on the other side, stay like this for the next 18 months or so, the current accepted timeline until there’s a vaccine. But Carroll and Jha argue that there is a third path available, somewhere in the middle of these two strategies. They think that once we do the social distancing necessary to get the initial numbers under control (which will still take time), we can create a new type of plan, a middle road that keeps public health manageable without keeping the country completely shut down.
This third path essentially requires us to do all the things we failed at the first time around. Here is a partial list of what it would entail: An enormous scaling up of testing, the ability to test nearly everyone, regularly, the willingness of even asymptomatic carriers to self-quarantine and isolate while they are sick with the virus (and help notify and test those they have been in contact with), and not least, an enormous expansion of the capacity of our medical system to accommodate for all of this. There’s also the investment in the creation and distribution of the vaccine, which everyone is sort of taking for granted but is far from a gimme.
We don’t know how long the societal benefits of sheltering in place will outweigh the societal harms. It’s maddening to wonder who we can trust to keep track of this all, and who will be making the decisions as to what we should do next. It’s worth remembering, as we watch Donald Trump’s current panic over the stock market, that we are in the terrible position of having to take drastic mass-isolation action only because of his federal government’s unbelievable lack of preparedness and initial inaction on containment. That laggard response has endangered us enormously. We’re much worse off than countries that invested in robust testing and self-isolation right from the start, like Singapore and Taiwan, both of which managed to contain this. And still, even in the face of enormous loss of life and economic devastation, the president is pathologically unable to let anything but his own narcissism determine our centralized response.
But the options cannot be the only two that we currently have a clear picture of. They cannot be that we either shelter in place indefinitely, without real, immediate relief from the federal government, or we just give up on mitigation and accept that the coronavirus will kill an incredible number of people. (The problem with trying to do the latter for the sake of the economy is that 2 million deaths would have a devastating effect on the economy regardless. We can’t just “start it up again.”)
I realize that getting us to a place where we can envision Carroll and Jha’s third way is like answering whether you should take the subway or a Lyft by suggesting that really, you ought to buy a car. But the answer of what we need to do is simply much larger than what we currently think we can do. The costs of the two other paths are simply too high for us not to figure this out. We can’t do nothing (and thank God we are no longer doing nothing). But we can’t pretend that what we are currently doing is a sustainable solution, either.
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