Our way forward needs to be a carefully calibrated level of “normalcy,” but the nuance of this strategy is lost in the US’s hyperpolarized political environment, says Nahid Bhadelia
In a recent open letter, UK public health experts asked the British government to pursue adaptive measures to covid-19 based on real time changes in the number of cases. They suggested the government would need to ease and reimpose restrictions to allow society to move “flexibly between (say) 90% normality and 60% normality.” The UK, in the face of an increasing number of positive covid-19 tests and cases, has since adopted some rollbacks by reducing the size of indoor gatherings and limiting opening hours for restaurants and bars. This seems to be the most apt description of realistic public health priorities over at least the next year.
In the US, it’s not so much the technical elements that make this strategy difficult, but a large political divide that makes a national vision impossible to achieve. As the world passes the grim milestone of one million deaths from covid-19, now is the time to take stock about how we survive the upcoming year.
There is general agreement across most spheres of public health and governance that second lockdowns are not desirable and need to be avoided at all costs unless we have failed at curbing transmission and are at the tipping point of overwhelming healthcare systems. The initial lockdowns could be justified because a blunt instrument was needed in the spring to curb cases immediately. It gave us time to understand more about the virus and how widespread the pandemic had already become by the time most countries started testing more widely for the disease.
Yet now in the ninth month of this pandemic, the path ahead seems a little less foggy. Most countries have seen the results of uncontrolled spread either firsthand or through the experience of others and know what is at stake. Our expectations of how long it will take to develop an effective vaccine and its ability to return us to normalcy are more realistic. But that realization of the potential long timeline ahead of us to get to the “post pandemic” world also reveals that we need to keep society open as much as we safely can.
I agree with the authors of the open letter that only “shielding the vulnerable” is not a successful strategy (where older people and those at high risk for severe disease are sheltered away from the general public and placed under greater public health surveillance). This strategy is likely to fail as there is now documented evidence of what common sense already tells us: vulnerable people do not live in a vacuum, and in the US infections among the young have ended up resulting in infections among older Americans too. Additionally, nearly one quarter of the US population is considered vulnerable to severe covid-19. Evolving data are also starting to paint a worrying picture of how even those with mild symptoms can go on to have so called “long covid.”
Our way forward needs to be a carefully choreographed balance, where we continue to pursue the commercial, social, healthcare, and educational endeavors important to our civilization, but use tools like testing and contact tracing to pick up worrisome trends of increasing cases and remain ready to roll back some aspects of normalcy. Our actions need to be based on cases and not delayed until we see hospitalizations and deaths rising. This is how we keep the economy going, how we send our children to school, and how we maintain our sanity while keeping our healthcare workers and loved ones safe.
We need to protect the vulnerable while turning the tap on “normalcy” low or high for all of us depending on what real time data tell us. This tap could control not just public activities, but also public health priorities, such as more targeted testing in areas where cases are rising. The lower our baseline cases, the larger our window to navigate the band of normalcy and the larger our margin of error. The larger our margin of error and more facile our ability to stay on top of trends, the less likely we are to have to be forced into a lockdown.
It’s up to each country to decide what warning signs herald reimposition of public health measures depending on their healthcare capacity. In the US, the Whitehouse guidelines Opening Up America Again provide milestones for phased reopening, but this needs to work both ways. They need to serve as reopening and rollback guidelines. Given the size of our country, these rollbacks and “reopenings” may need to be regional in nature. The plan is already there. What we need is a unified national vision of what we are trying to achieve.
To achieve this type of societal synchronization in action and purpose, we need to have widespread agreement on the importance of curbing cases in this pandemic, which we currently lack. There are still segments of our politicians who are pushing for infection induced herd immunity, without realizing that even under this misguided strategy as a goal, the rate of infections would need to remain low so as not to overwhelm healthcare systems. This is assuming we don’t continue to see reports of reinfections increase from this novel virus as we move farther away from the start of the pandemic. Controlling the virus also appears to be the best strategy for economic survival. It is no coincidence that just as the US is one of the hardest hit high income countries in terms of cases and deaths, it has also experienced an increase in its unemployment rate which is five times that of other member countries of the Organisation for Economic Co-operation and Development (OECD).
Whether we can safely exist in the band of 60 to 90% normality depends on if we can get public understanding and cooperation with public health measures, such as masks and physical distancing, and whether businesses and schools can adapt to requirements for safer operations. It requires population level buy-in. However, the nuance of the “band of normality” strategy is lost in the hyperpolarized political environment here in the US.
It is absolutely critical to bridge this divide if we are to maximize our outcomes over the course of the pandemic. Instead, the lack of adequate information on a regular basis from our government officials about this pandemic feeds into this divide. It has created a vacuum filled in by many voices, including real citizen experts, but also pseudoscientists and nefarious actors. The US, for example, has sporadic COVID-19 Taskforce briefings and sometimes without scientists at the podium, and the taskforce does not publicly release its weekly reports. One way we can improve common understanding around a national vision of this pandemic is to increase and amplify reliable sources of information from longstanding reputable or bipartisan sources. Three possibilities could help.
Firstly, there needs to be more public education to clarify the differences between a lockdown and a carefully navigated strategy of rollbacks and reopenings. We need more scientists from the Centers for Disease Control and Prevention, unfettered by pressure from political appointees, at the forefront speaking out, cutting through the haze of other sources. During this pandemic, we have lost the voice of the very government body that is meant to serve as a beacon of clarity.
We also need to acknowledge that there is no longer any way to separate the politics from the pandemic in the US. We need reasonable leaders on both sides of the political divide to call for an effort to help identify and articulate our common vision. We need the media to make a concerted effort to highlight these unifying voices.
Lastly, professional societies, such as the American Medical Association, American Public Health Association, Infectious Diseases Society of America, and others should consider forming a broad based coalition that hosts weekly updates on the pandemic in the country.
All epidemics eventually end or transform into endemic threats. But before they end, they exact their toll in lives, sickness, in economic and cultural costs, and societal psychological scars. As we barrel past one million deaths globally, it’s a reminder that the world we see today is a result of the priorities we set before this pandemic. The world we see after this pandemic will reflect the priorities we set today. What do we value and seek to protect?
Nahid Bhadelia is an associate professor of medicine at Boston University School of Medicine and medical director of the Special Pathogens Unit at Boston Medical Center. Twitter @BhadeliaMD
Competing interests: None declared.