There's an ancient Greek myth about Cassandra, daughter of the king of Troy. After rebuffing advances from the god Apollo, she received a gift . . . and a curse. (It can never be simple in a Greek myth.) The gift was that she could see the future. The curse was that no one would believe her.
For the past few months, the public health community has been feeling Cassandra's pain. Medical science has given us the unprecedented ability to identify and genetically sequence new infectious diseases, and data analytics has given us the power to see outbreaks coming. Biomedicine has given us the ability to begin developing diagnostics, therapeutics and vaccines within hours of identifying an outbreak caused by a new infectious organism. But in the case of the coronavirus, it has often felt as if no one is listening.
The consequences have been catastrophic. Tens of thousands of Americans did not have to die. As a recent JAMA article showed, compared with other high-mortality countries such as Italy, the United States has had 44,000 to 104,000 excess COVID deaths after the initial wave overwhelmed health systems — between 22% and 52% more.
The United States had plenty of warning — and advice from world-leading experts. As we head into the fall and winter, we have to go back to the future to avert disaster. We have to actually implement the advice that was being given in March by the public health Cassandras, and we need to do so now. Here are four steps to avoid another catastrophe in the coming months.
Implement nationwide testing: Former FDA commissioner Scott Gottlieb in March called on the federal government to increase lab testing capacity. When it didn't, the consequences were disastrous. As he told USA Today, "It's probably the case we have multiple, large outbreaks in major metropolitan areas that we are unaware of."
That is why he and others called in the spring for a nationwide surveillance system for the coronavirus, understanding that relatively small investments in our existing public health surveillance infrastructure could help us stay on top of local outbreaks. The great advantage: We could avoid widespread lockdowns using much more selective approaches to prevent community-wide spreading events.
Such surveillance would depend not just on more testing but on "smarter testing." Instead of simply focusing on positive test results, we need serosurveys of multiple communities; we need the Centers for Disease Control and Prevention to move rapidly to help states and localities set up "sentinel testing" to act as an early warning system; and we need to investigate the data we already have through systems like syndromic surveillance. We needed to do all of this to answer four questions: Is the outbreak in a city or state getting better or worse? And how fast? Who is getting COVID-19? And what are their outcomes? Today, we don't have better answers to those questions than we had seven months ago. But if we want to keep opening up businesses without triggering large-scale outbreaks and shutdowns, we have to put these systems in place between now and Thanksgiving.
Get more PPE to the front lines: Former Centers for Medicare and Medicaid Services administrator Andy Slavitt quickly saw that a lack of planning for personal protective equipment would put health-care workers in danger. In March, he called on Congress and the administration to make a massive investment in PPE for these workers. He called for 1 billion N95 masks to be distributed and to "protect the most vulnerable Americans from COVID-19: people with underlying chronic medical conditions, those living in close quarters or otherwise unable to practice social distancing, and seniors — especially those in nursing homes." Indeed, at one point, the U.S. Postal Service was planning to send out five masks to each American household. But that plan was nixed for unclear reasons.
It is hard to believe, but seven months into this pandemic, many nursing homes and other health facilities across this country still didn't have enough PPE. A big part of the problem remains that manufacturers and innovative companies are willing to ramp up production in the United States only if there is predictable demand, so they aren't left with excess capacity and supplies that negate their investments. Just as it is doing with vaccine manufacturers, the federal government needs to sign long contracts for PPE to give manufacturers predictability and then distribute the supplies to vulnerable Americans and health facilities in need. And it still wouldn't hurt to go through with the original plan and send masks to each household: A Washington Post-ABC News poll in July found that nearly 8 in 10 Americans said they wore a mask whenever they left the house.
Enforce reduced crowding: Early on, states limited gatherings to 10 or 25 people. That rule has since been relaxed — which was a mistake. We now know definitively that the coronavirus spreads largely in groups. As experts have noted, 80 to 90% of infected people don't spread the virus to even one person. About 80% of cases arise from superspreader events, such as a Biogen corporate conference in Boston, the Amy Coney Barrett White House event, weddings, funerals, religious services or frat parties.
Now that the virus is spreading out of control again, we have to return to limiting indoor events and group sizes. And we have to enforce those limits. Modeling suggests that restricting groups to fewer than 20 people can effectively curb transmission and outbreaks and, thus, COVID-19 cases. This means no indoor dining or bars, and limiting weddings and other events to groups of no more than 20. This is painful and hard, but it's necessary.
Implement effective contact tracing and isolation: Former CDC director Tom Frieden unveiled a simplified version of this strategy in April, calling for Americans to "Box It In." It was a strategy to effectively isolate people infected with the coronavirus, find whomever they had come into contact with and encourage those contacts to quarantine for 14 days. That concept, too, went largely unheeded by state leaders when they began reopening in the summer. Other countries track people, sending them messages when they break the quarantine and requiring that they test during quarantine to ensure they don't infect others.
The people who issued these warnings and suggestions represent the knowledge and expertise that exists in various offices in the federal and state government. We need leadership that will empower these voices to speak out and efforts to effectively implement their recommendations.
Cassandra was cursed. But we're not living in a Greek myth. We don't have to ignore the advice of public health experts yet again. As we prepare for the predictable resurgence of the coronavirus, we still have time to heed the warnings, put plans in place, empower the experts. Our first response to the pandemic — and the mistakes of ignoring experts — does not have to dictate the next response. We can still turn the corner and do better. We have to.
Mostashari the chief executive of Aledade, a company he co-founded that helps primary care doctors form accountable care organizations. He is the former national coordinator for health information technology at the Department of Health and Human Services. This piece was written for The Washington Post.
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