Second Time Around

As the Western world was first hit by mass spread of the novel coronavirus last spring, governments acted with near uniformity in enacting shutdowns of society, shuttering schools and all establishments deemed “non-essential.”

Amid spiking rates of hospitalizations, deaths, and fears about the virus, the vast majority of Americans accepted the multifaceted challenges of lockdown.

There were factors that pushed the public to give elected officials much leeway. A pandemic of this sort had never been dealt with in the nation’s recent memory and lack of preparedness was understandable. While no one knew exactly what to expect, most people were under the impression that it would not be more than a few months before life could return to normal.

Moreover, there were specific reasons why shutdowns were the only way to go. Even if much of the virus’ spread would prove uncontrollable, it was imperative to “flatten the curve” to keep hospital systems from becoming overwhelmed — something that happened to a large extent in cities like New York.

It was widely reported that better options than lockdowns existed, with many pointing to South Korea as an example of a country that had been able to control the virus without draconian restrictions through mass testing and forced quarantining. A dire lack of accurate testing materials and large-scale community spread made the strategy impractical for containing America’s outbreak. Yet, public health experts held out optimism that time and investment in a robust testing and tracing infrastructure would change the face of future COVID spikes.

As a second wave sets into many parts of the country, New York City and other locations seem to be borrowing from a similar playbook as this past March, closing public schools and businesses as the city’s positivity rates drift higher.

Testing is far more available than it was initially, and while some private companies and organizations have successfully harnessed screening, few areas of the county have been able to use it as an effective tool to control outbreaks and avert the specter of shutdowns.

Such an approach has citizens and many public health experts wondering why government seemingly has so few cards to play against the COVID pandemic, nine months after its arrival first upended daily life.

A Failing Mark on Testing

The concept of using mass testing to mitigate both the health and societal impacts of COVID is relatively simple. By regularly testing the population randomly, non- and pre-symptomatic carriers can be identified. They and their contacts then quarantine, which at once curbs spread and allows others to continue their lives, with the probability that a high number of infectious individuals have been “pulled out” of the public sphere.

The strategy bore successful results not only in South Korea, but also in Taiwan and Vo, a province in Italy that was hit early in the outbreak but quickly contained the spread.

Edward Kaplan, a professor of public health at Yale University, pointed to the system that his and other universities had established as a model of the effectiveness of mass testing. At Yale, all students and staff are given PCR tests twice a week with results turned around in 24 hours as part of a private arrangement with a Boston-area laboratory.

“Twice a week would be too much for most of the population, but we had a theory as to why this would work and our models showed that if we only tested once a week, we would have had double the amount of infections. It’s not just about finding cases, but isolating them,” said Professor Kaplan. “Our goal was to keep infections below 5% of the student body and, in reality, we’ve been able to keep it under three [percent].”

Professor Kaplan pointed out that while governments do not have the luxury of a well-funded Ivy League school, models exist that could allow even large municipalities to maximize the impact of testing.

“Make a list of areas and rank them according to risk. Typically, poor, densely populated neighborhoods will be at the top. Set up a fleet of mobile testing units and make a campaign encouraging everyone to get tested. If the places higher on the list are not as heavily impacted as you thought, move down the list. At the same time, you want to do a certain amount of random testing in other parts of the community to get a sense of the entire population’s infection level,” he said.

Due to the challenges many who test positive face in effectively isolating themselves, especially those living in small, crowded living quarters, an important component of such a plan is for government to provide temporary housing for COVID patients as well as incentives for taking advantage of these facilities.

The dearth of testing also leaves public officials with limited and likely inaccurate data.

“Testing is not only being done very sparsely, it is mostly being done by individuals who are seeking to get tested, which introduces a bias in the results,” said Awi Federgruen, an expert in statistical analysis and applied sciences and a professor at Columbia University. “We don’t even have a good picture of something as basic as the infection rate, but these faulty figures continue to be relied on to make policy.”

Doug Badger, senior fellow at the Galen Institute, a health care policy think tank, recently penned an article arguing for the FDA to approve more rapid tests that people can perform themselves at home.

“They’re not a hundred percent, but don’t let the perfect be the enemy of the good. The more frequently testing is done, the less likely it is to get faulty results,” he said.

Mr. Badger said that he was encouraged by a recent statement by Dr. Anthony Fauci endorsing a plan to flood the market with rapid tests.

“Right now, our policies are based on ignorance. I don’t know if I have COVID, so I wear a mask, I don’t know if you have it, so I stay six feet away. This is a way to replace ignorance with knowledge,” he said.

With plans of how to harness mass testing in place, the question remains as to why so little has been done to use it effectively — especially over the summer months when most of the Northeast had a respite from high levels of infection.

“We didn’t use the intervening time smartly,” said Mr. Badger. “We’re still not doing what we can on testing, and we’re heading into another crisis with nursing homes — which is where you would think officials should have focused. The private sector has done a lot on therapeutics and stepped up to the bat, but you can’t say the same for a lot of government.”

Many have pointed to state and city officials for failing to develop sufficient testing and tracing systems. New York’s Mayor Bill de Blasio spent months touting his city’s corps set up to do just that, but even before the second wave of infections set in, few saw signs of New York being positioned to beat back a rebound in cases. Some have pointed to a lack of coordination and unified standards between the city and state level as playing a significant role in the apparent lack of second wave preparedness.

Professor Kaplan, however, argued that blame rested with the federal government.

“The states do not have the resources on their own to do this; they’ve already been stretched so terribly,” he said. “I am a big supporter of Operation Warp Speed, but the President put all of his eggs in one basket. The federal government needed to step in for mass testing and quarantining to really work. If you think about it, the military is probably best positioned to help with the logistics with the help of private sector companies like Amazon and FedEx to help move all the samples around.”

Sticking to a message he repeated often of criticizing the Trump administration’s pandemic response, Professor Kaplan also said that the frequent cases of COVID within the White House’s staff showed the limitations of relying solely on rapid testing without components of masking and social distancing.

While some foreign countries’ use of testing has raised questions as to why America has failed to follow suit, some point to societal differences as the culprit.

“Contact tracing in New York is not up to par and long delays in test results have jeopardized the ability to use them to stop the spread, but there are serious cultural challenges as well, with American’s concept of individual liberties. In South Korea, there is strict adherence to quarantine. Once someone tests positive, they are moved into a quarantine facility. That’s very different than telling people to stay at home or making facilities available like we’ve done here,” said Professor Carri Chan, an expert in health care operations management who teaches at Columbia University.

Schoolhouse Lock

Over the summer, officials pursued options for school operations including partial and full in-person instruction, but as cases spiked in recent weeks, several in affected areas have begun to pull back.

Mayor de Blasio’s decision to close New York City’s public schools after infection rates hit 3% was widely criticized. His administration insisted that the figure was based on scientific recommendations and pushed back against accusations that it was determined through negotiations with the city’s powerful teachers union which had resisted plans for in-person instruction. Yet, one of the city’s top medical advisors, Dr. Irwin Redlener, admitted in a recent interview that the figure was “arbitrary.”

What has drawn additional ire from many is that, while viral spread has increased in the city at large, cases in schools remained low and expert data showed schools to be a low-risk location for infection.

“If the city or state had data to show that spread was coming from schools, that would be different, but that is not the case. Statistics show that spread is not happening in schools,” said Professor Chan. “It seems more risky to close schools and then have working parents have to find alternative caregivers than to have kids in class social-distancing and wearing masks.”

Another complaint lodged against the city’s decision is that students were sent home while bars and restaurants remained open in many parts of the city.

Confronted with the criticism in an interview, Mayor de Blasio responded that bars and restaurants would likely be shut down soon as well, but offered vague details on how and when schools would reopen, saying only that more rigorous testing would need to be put in place.

“New York City schools were the first target when you would think it would be the last, since keeping schools open has enormous benefit and the cost of closing is enormous,” said Professor Federgruen. “It seems to be coming more from political considerations and that the Mayor allowed his hands to be tied down to an arbitrary metric by the teachers union. At the same time, you have a Mayor and a Governor each fighting to impose their rules. Given the stakes of children’s education and parents’ livelihoods, it’s pretty depressing that this is what the planning looks like.”

Lockdowns?

In March and April, nary an official press conference was held without mention of a need to “flatten the curve,” and that lockdowns were an emergency measure to help hospitals preserves stocks of Personal Protective Equipment (PPE), ventilators and oxygen machines, and to free up ICU beds, and staff needed to treat a storm of COVID patients.

“The hospitals I’ve spoken with have been working around the clock since the spring getting ready for this,” said Professor Chan, who has been involved in planning efforts at Columbia Presbyterian Hospital in New York and consulted with many others. She pointed specifically to efforts to stock up on PPE and to develop dashboards allowing hospitals to better track infection rates as a means of knowing when to adjust their operations to focus more on COVID patients.

“In the spring, many hospitals were caught by surprise and things like elective surgeries got shut down very suddenly. The idea is not to have to do anything like that and if there is a need, to do it more gradually,” said Professor Chan.

Professor Chan said that while hospitals themselves had taken significant steps to increase preparedness, missing in New York was a central data base maintained by the city that would allow planners to see if more space exits in another health system and to aid in organizing transfers.

“On a city-wide level there are still challenges across systems since there’s no one database that updates in real time and allows them to coordinate between hospitals,” she said.

Another factor that many hope will mitigate some of the worst of what occurred over the spring is the development of several effective therapeutic such as convalescent plasma, Remdesivir, and high-flow oxygen as well as protocols to keep more patients away from intubation.

As the second wave of infections intensifies, New York’s hospitals remain within capacity marks but in many other regions, hospitals are struggling to keep up with the spike.

Mr. Badger was hopeful that advances would decrease the need for drastic measures to help hospitals cope, but said that targeted shutdowns might still be necessary.

“You might still need episodic lockdowns to preserve capacity,” he said. “If you look at a place like North Dakota, they only have something like 132 ICU beds in the state, but states like Massachusetts and Connecticut are still half empty.”

The value of keeping lockdowns highly localized is at the core of what many public health experts hope was learned from COVID’s first wave.

Additionally, several scientists, including a group affiliated with the World Health Organization, have increasingly warned against the effectiveness of broad lockdowns. A more recent study published in the journal Natural Human Behaviour, found that strong education on the importance of social distancing, banning large gatherings, and restricting travel proved as effective as shutting society down, while avoiding its more harmful results.

“Lockdowns were originally presented as an expedient, but they evolved into something that is being used as a solution, which it really can’t be, because whenever you open up, the virus will still be there,” said Mr. Badger. “The unfortunate result was that too many officials became obsessed with a limited playbook of lockdowns and social distancing and failed to do what they could have done to make themselves more prepared to deal better with the second wave.”