COVID 19 Update: Surrender

*This post will be more opinionated that previous posts on this subject.  My opinions are based on facts as I understand them and are not necessarily those of the leadership of my medical group or profession.

In a viral outbreak or pandemic for which no vaccine and no known effective treatment exists, public health measures can still alter the natural history of the pandemic.  There are 3 basic public health strategies from which to choose:  Containment, Mitigation and Herd Immunity(achieved through no intervention and allowing the pandemic to complete its natural course).

Containment is most effective early in the course of a pandemic when there are relatively few cases, but is difficult to implement quickly enough due to lack of time to ramp up resources.  Effective containment requires the early and rapid identification of cases, mandatory quarantining of cases, robust contact tracing with mandatory quarantining of contacts for a time determined by our knowledge of the natural history of the disease(how long is a person contagious?).  There are several countries who appear to have successfully contained COVID 19 including South Korea, New Zealand and Germany, although it remains to be seen if containment can be sustained over the full course of the worldwide pandemic.  There were early attempts at containment in the U.S.  An early outbreak in New Rochelle, NY was found to have started with one individual who then spread it to multiple citizens of the town.  New Rochelle was locked down and essentially quarantined as a community.  Unfortunately a much larger outbreak had already started in New York City and the rest is history.  In San Diego, one significant outbreak was traced to a small group of friends who were apparently infected while on a ski vacation in Colorado and brought it back home.  Another large outbreak was traced to a single infected individual who attended an electronic music event and transmitted it to multiple contacts.

In one large hospital in Northern California, contact tracing identified over 100 hospital workers who were exposed to a single infected patient.  All contacts were placed on a 14 day quarantine which caused significant staffing problems in that hospital.  As more and more cases came to hospitals, it quickly became impossible to quarantine contacts and still keep the hospitals open.  Testing was only available through the CDC via local health departments and took several days to turnaround.  Hospitals filled up with sick patients waiting for test results.  The caseloads quickly overwhelmed health department resources to carry out contact tracing.  Strategy quickly shifted to mitigation.

I think by now we all know what mitigation entails: Social distancing, personal protective equipment, closing schools, social events, entertainment events and some businesses.  There can be a spectrum of degrees of mitigation ranging from voluntarily avoiding large crowds and wearing masks in public to total lockdown.  The value of testing is less clear in mitigation.  It is still used in hospitals to try to segregate patients with COVID 19 from other patients.  It can be used to determine patients who are candidates for clinical trials of investigational medications.  Testing can also be done on random population samples, like a poll, to determine prevalence of active virus in the community.

There are several potential goals of mitigation.  Best case scenario is mitigation reduces the number of new cases to the point of enabling a return to a containment strategy.  A few countries who have applied draconian lockdowns have managed to get to this outcome.  Another goal is to "flatten the curve" which does not stop new cases from occurring, but keeps them at a low enough level that the healthcare system is not overwhelmed.  There is evidence that case-fatality ratios approximately double when healthcare systems are overwhelmed.  Infections and deaths among healthcare workers also increase significantly when the system is overwhelmed.  Another potential positive outcome of mitigation is delaying infections until an effective vaccine or medication is available.

Mitigation does come at a severe economic cost with skyrocketing unemployment and general loss of economic activity.  Whether that economic cost is greater than would occur naturally in an uncontrolled pandemic is uncertain.  So far, every country and region except possibly Sweden has eventually been forced to institute mitigation efforts in response to crushing disease burden.

The U.S. has never had a coordinated national strategy for managing the COVID 19 pandemic.  Strategic decisions regarding the employment of containment vs mitigation vs doing nothing have been left to state and local governments.  The federal government has nominally supported mitigation but has not enforced it or even vigorously encouraged it.  We are now actually seeing widespread examples of federal and state government blocking local containment and mitigation efforts.

Last week, the President of the United States surrendered to the virus and abandoned mitigation.  Make no mistake.  This shift in strategy is not because the President thinks mitigation has been successful and we can now go back to containment.  Mitigation may continue to some extent at state and local levels, but the national strategy now is to let the pandemic follow it's natural course and get to herd immunity as quickly as possible.  You don't believe that?  Here's a direct quote from the President's interview with David Muir of ABC News:  "There'll be more death, that the virus will pass, with or without a vaccine....and I think we're doing very well on the vaccines but, with or without a vaccine, it's going to pass and we're going to get back to normal.  But it's been a rough process.  There is no question about it."

I will let readers decide whether they think this is the correct strategy.  It is my opinion that the economic impact of an uncontrolled pandemic and an overwhelmed healthcare system will be as great or greater than what we have experienced with mitigation, but it may well shorten the duration of the economic pain.  We need to be clear-eyed about where this will take us.  My own calculations, which I have outlined in previous posts, as well as calculations of multiple pandemic experts is we can expect a final death toll of somewhere between 0.5 to 3 million in the U.S.  I hope I am wrong and it is much less than that.