Time to reopen? A conversation with Stanford epidemiologist Dr. Steven Goodman.
Are they crazy?
That?s my visceral reaction as I watch the evening news and see crowds of people mingling freely in places that are easing their Covid-19 restrictions. I feel as if I?m watching a horror movie and I already know the ending: Protesters shaking their fists, pastors claiming that God will protect them ? these will be the first casualties of the inevitable next wave of infections and deaths.
Am I too paranoid? Is it time to resume normal life? These are questions many are understandably struggling with and few can responsibly answer. I happen to have an epidemiologist in my family who I routinely turn to these days. Steve Goodman, MD, PhD, is an associate dean at the Stanford School of Medicine, where he is professor of epidemiology and population health, and medicine. This is the third ?Covid conversation? that Steve and I have had. This story is adapted from our live discussion on The Vermont Conversation, a public affairs radio show.
Elemental: What is the current state of the Covid-19 pandemic in the U.S.? How do we ease restrictions?
Steve Goodman: The virus has no memory. It has no politics. It?s just sitting there. Think back to early February when we had no cases anywhere in the U.S. That?s where we are returning to right now. Some places are looking pretty good ? just like we thought in January and early February. But the virus is out there and it is just waiting for us to start mixing and interacting as restrictions are relaxed. Then you can go from the proverbial zero to 100 in 60 seconds. The virus doesn?t give us any credit for having knocked it back.
As we reengage, we?re going to have to think about how we monitor things and how we keep the virus from roaring back, instead of coming back at a controlled level. We can begin to live our lives but also deal with this in a way that will protect us while incurring some risk ? and there?s no question we?re taking a risk. How to strike that balance is going to be a phenomenal challenge for this country.
You can go from the proverbial zero to 100 in 60 seconds. The virus doesn?t give us any credit for having knocked it back.
Is it appropriate at this moment to relax restrictions?
That?s a very local decision. And it depends which restrictions we?re talking about. Should we be able to go to more businesses and enter one or two or three at a time? Maybe. It depends on the local conditions, on how many cases they?re seeing, how many hospitalizations, how far back we?ve knocked the virus.
There have been a number of plans put forward for how we reenter. But what?s absolutely key is that we have some sort of monitoring system in place, whether that be testing or symptom tracking. Something that tells us as fast as we can whether the relaxation is producing a surge in new infections, or even a few new infections, so we can do something about that. Unfortunately, that infrastructure is in place almost nowhere.
Where are we at with testing now and where do we need to be?
We need to have the capacity to test large samples of the communities repeatedly. We need millions of tests per week to do that. We?re just testing in the tens of thousands. We?re nowhere near where we need to be to have a protective radar for the community.
Is it too soon to relax restrictions? There are certain communities and certain regions where they?re primed to do it. But the problem is that without testing they won?t be able to tell whether it succeeded or failed until it?s a little too late. They won?t know until about three or four weeks later, and we already know that this virus has the potential to double every three days if it?s running wild and we?re not distancing.
We can use the strategy that all the Asian countries use: When you just have a few test-positive cases, you quickly isolate them, trace their contacts, and then you snuff things out. But without testing, you lose the ability to do that. Then you?re just waiting for another wave. So we?re not really ready for meaningful reengagement in most of this country. But I?m very hopeful that we will be soon.
Why are we so far behind in testing? Countries like South Korea have been testing millions of people from the beginning.
It?s a really simple answer: no national leadership. We have no national initiative on testing. The one potential central leadership that we could have had was from the CDC. But they had problems the minute they decided to develop their own tests. The World Health Organization had a perfectly good test, but the CDC decided they didn?t want to go with the WHO test. This is the same WHO that our president has just defunded because he says they are the source of the problem. When we were just beginning to gear up on testing, WHO had 10 million tests ready to go ? a number beyond our imagination even now.
We?ve had no national leadership on the development and dissemination of the test, or the development of the supply chains for all the materials that are necessary to do the tests. We don?t even have enough swabs to do these tests. And the testers need the same personal protective equipment that doctors in the hospital have, and that?s in short supply.
It?s sort of every state and every region and every county for themselves. And that is not how you mobilize a country to fight the battle that we?re in right now.
We now have results from countries that have successfully managed the pandemic and countries like the U.S. that haven?t. Who has managed it well?
One of the most interesting case studies is Taiwan (population 24 million). Their economy is humming right now. The stores are not shut down. The kids are going to school. Everything is fine. They had their early cases close to when the U.S. did. They were prepared right from the start and right from the top. They had a national plan in place. They were scarred by the SARS epidemic. They developed a national plan that involved all the agencies of government. They were holding and testing people at all border points. They pre-built a headquarters to hold all the key leaders and every agency that needed to be involved specifically for epidemic control. They had the masks in production from day one and they ramped up from 2 million to 10 million a day within a month. It was an all-points coordinated effort to control this with massive testing, massive distancing at the beginning, and case finding and isolation ? all the components that we would need to put in place with coordination and a national strategy. They stopped the epidemic in its tracks. China and South Korea beat it back by brute force. Taiwan beat it back by very strategic force, and their lives have not been that disrupted.
One of the most interesting case studies is Taiwan. Their economy is humming right now. The stores are not shut down. The kids are going to school.
Let?s turn to the questions that many people have right now: Will students be back in school in the fall?
If the decision were made today, most schools would probably not open in the fall. But there are many things that could happen. Testing could ramp up. We could find more effective therapies to prevent death or serious damage. Any one of those would be game-changers.
We have to figure out how we can engineer a middle ground between zero tolerance, which is sort of what we have right now. How can we relax restrictions to the point where the amount of infection that occurs can be managed and tolerated and suppressed while still letting our economy go at some level? This is going to have to be a collective decision.
There?s no way we can go back to the same situation that we had before. But maybe we can find a level of economic activity and a way of interacting with each other so we can prevent the complete collapse of local economies by allowing Covid to come back at a manageable level while trying to protect the most vulnerable people. It?s going to be tremendously challenging. We need smart people, smart planning, and smart infrastructure to do that, but I think that?s where we?re going to want to aim. If we have zero tolerance, we?ll have deaths just from the collapsing economy. It?s not going to be the economy versus deaths; in part, it?s going to be deaths from the economy versus deaths from the virus.
How long do school officials need to wait before making that decision?
Given what we know today, I think many school systems or universities are going to take what they view as the safe route, and probably continue distance learning.
These experiments with relaxing restrictions are happening state by state right now. In two weeks, we?ll know more than we know today. If school officials can wait a month to make that decision, they?ll have a lot more information about the consequences of certain forms of relaxing. Every state is a laboratory. We?ll watch and see what happens in Georgia right now, and in California. Then we can make some informed decisions.
How does the Covid-19 story end?
If we can?t find an effective treatment, it ends with either the disease burning out, or with a large percentage of the population becoming immune through getting sick and some dying, or through vaccines. There?s no other way that epidemics die out.