People keep their distance as they wait their turn in a queue to access a supermarket in Barcelona, Spain, on Monday.
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Jeremy Samuel Faust is an emergency medicine physician at Brigham and Women’s Hospital in Boston, an instructor at Harvard Medical School, and a Slate contributor who’s been writing about the coronavirus crisis. His hospital is currently screening incoming patients for the people they know are coming: those affected by COVID-19. In fact, Faust is already seeing things he’s never had to confront before. But his years of experience in emergency medicine give him a clue as to how we should be directly confronting this crisis and ensuring everyone’s safety as much as possible.
On Monday’s episode of What Next, I talked to Faust about what being in the ER has taught him about all the bigger decisions that are happening right now, and why social distancing and lockdowns alone aren’t necessarily the answer. Our conversation has been edited and condensed for clarity.
Mary Harris: In your ER right now, if I show up and I’m coughing and have a fever, what happens?
Jeremy Samuel Faust: It depends on your risk factors. You certainly are considered for testing. Fevers are being taken very seriously. The tricky part is patients who don’t have a fever. That’s where it gets hard.
Why?
Because we don’t know how many of these patients are running around with no symptoms or mild symptoms. We know the case report out of China where somebody was tested for the coronavirus because they were known to be exposed. That person tested positive, but we know they never got any symptoms. They’d also transmitted it to five other people. That’s scary because we have so many people who can spread this, but it’s also a little reassuring because some people get it and don’t even know about it. So they might not even be participating in the statistics that tell us how dangerous this is in terms of the fatality rate.
You wrote an article for Slate where you said, basically, the coronavirus isn’t as deadly as you think. But at the same time, you’re advocating for everyone to be tested. Can you square those two things for me? Because I think some people would think those were in conflict.
The headline was “COVID-19’s Mortality Rate Isn’t As High As We Think.” I was specifically referring to statistics that the World Health Organization has been putting out, that the case fatality rate was around 3.4 percent. I stand by that piece, though I do think the virus probably is that deadly for a certain population. What I was trying to get at is that for people who aren’t hospitalized or have already been tested, it’s far, far less fatal. The numbers are coming down the more people we test. My approach is, let’s test everybody because that’s the way to measure a lower fatality rate. And I think that would have a really good effect. First of all, it’s more accurate. Second, it ramps down the fear.
The numbers we’re seeing around the world are reflecting the fact that doctors have mostly conducted tests on the very, very sick, and very few places have tried to test larger nets of people in their communities. South Korea has done that. They had hundreds of thousands of tests, far more than we’ve been able to do. South Korea had the courage to detect a higher number of cases, but in exchange, they got something else, which is finding out that, oh, most people don’t die from this, actually.
I live in New York City, and the governor and the mayor are talking about these stringent steps to control the spread of this coronavirus. But what I hear you saying is if we had the tests, we might not be resorting to those steps. Or we might be able to target those steps a little bit better because we’d know more about what we were dealing with.
"In some areas, a one-size-fits-all blanket approach to social distancing could be harmful." — Jeremy Samuel Faust
I think one of the reasons we are so panicked as a society right now is we don’t know what the hell is going on. This totally matches my experience as an ER doctor: It’s not bad news that patients recoil from—it’s uncertainty. If I tell them I don’t know what’s going on, that is untenable for people. They just cannot deal with that because they imagine the worst. And depending on the personality, they can react in many different ways. What’s happening now is we don’t know what’s going on in terms of where the virus is and how many have it, how many are going to be affected by it seriously.
The most important thing we can do is remove that uncertainty by testing everyone and knowing where it is. And then we can say, look, it’s not here, it is there. And here’s what you do. Here’s the fatality rate.
I’m seeing this thing locally where people with a lot of money and time can have very different experiences of this disease than people who don’t have those things. I guess that’s the story every time. I wonder if you think about that because you’re in the ER, which is the ultimate place where if something’s going wrong, it’s going to land on your doorstep.
Emergency departments are also the places where we see social determinants of health and health care disparities play out every day. For this reason, I think that a one-size-fits-all blanket approach to social distancing is not only a bad idea—in some areas it could be harmful. No one’s really doing the analysis. Closing a school could cause deaths because parents are still going to work and the kids are gonna be watched by Grandma. And we know from past epidemics that people, children in particular, do not follow lockdown instructions. So closing schools does not necessarily count as effective social distancing. In all cases, it counts as social distancing, but it could backfire.
But doesn’t it make us safer to close more things down and just keep to ourselves for a little while?
That’s true if you can really actually accomplish that, but we know that doesn’t happen. We know that kids go out. We know that people have to leave the house. I’ll give a historical example. San Francisco 100 years ago was one of the most draconian cities in the country in terms of what it did for social distancing: shutting the city down in order to prevent the spread of the 1918–19 flu. But then it ended up actually having one of the worst access case fatality rates of any large city in the world.
It’s funny you bring that up because over the past couple weeks I’ve heard so much about how St. Louis shut everything down during the 1918 flu and how it did so much better than, say, Philadelphia, which didn’t.
In retrospect, we add narrative to these facts. We say, oh, St Louis did it this way, and that’s why this happened. We can’t know that. I’m sure that a lot of these measures are good, but I’m very worried. I have seen data both in the present and in the past that there are areas where this can backfire. Think about it and figure out what makes sense in your area. Maybe the pendulum is going to swing toward more social distancing now than I was hoping for. But some areas might not. Let’s get the pendulum swinging and figure out where it really needs to land.
The opinions expressed in this article are solely those of the author and do not reflect the views and opinions of Brigham and Women’s Hospital.
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