Tom Frieden | Vox

5 ways to prevent another 100,000 coronavirus deaths in the US (and beyond)

2020-05-27T15:59:48-04:00

Paramedics assist a Covid-19 patient to her home after her recovery from an emergency C-section, in Stamford, Connecticut, on April 25, 2020. | John Moore/Getty Images

As we hit a gruesome milestone — 100,000 reported deaths from the novel coronavirus in the United States — we must focus on the single most important part of the response: saving the most lives.

The SARS-CoV-2 virus is likely to kill more than 1 million people worldwide by the end of this year, and 60 million people will die this year from other, often preventable causes, as they do every year. As we confront the most devastating infectious disease threat the world has faced in a century, unless we are more careful, there will be many more avoidable deaths, not just from Covid-19 but also from the disruption it causes.

If there’s one constant in the varying effectiveness of responses in different cities, states, and countries, it’s the tight correlation between how fully political leaders are guided by and support public health (for example, in Singapore, Germany, New Zealand, Seattle, and elsewhere) and how well they prevent their people from being killed by the virus.

To save as many lives as possible, both from the coronavirus and other causes, public health specialists must guide and political leaders must fully support five things at the core of public health.

1) Fix the glaring gaps in data about deaths

Although deaths are not an early indicator of the spread of the coronavirus and other health trends, tracking death rates is crucial to understanding and counteracting the impact of the pandemic. Tracking deaths identifies increases from the virus missed by testing and tracking systems and provides an early warning if deaths from other conditions increase.

What gets measured can be managed, and so every US state and every country must report all-cause mortality every week. Many higher-income countries can start weekly reporting by age group compared with historical levels, as Switzerland and others have done.

Even in the United States, this information isn’t readily available, and in places ranging from New York City to Georgia, public health leaders have had to resist pressure from political leaders to hide this key data.

We need to change the expectation so that we learn the death rates every week, in every community — both deaths caused by the coronavirus and all deaths. In lower-income countries where basic vital registration systems are often weak or lacking, this will require training, supporting, and paying community health workers and hospital registrars and also improving the capacity to collect, analyze, and disseminate real-time data. Last week, our organization, Resolve to Save Lives, joined the World Health Organization and others in releasing practical guidance on how countries can do just that.

In the US, this increase in deaths from other conditions, which results from the pandemic’s disruption, could come in the form of more heart disease deaths among those who didn’t seek care during the pandemic. At the height of the pandemic, a colleague in a New York City emergency department commented to me, “We’re seeing no angina.” It’s likely that patients with heart attacks avoided care for fear of contracting the coronavirus.

In Africa, meanwhile, falling immunization and malaria treatment rates could cause millions of preventable deaths. These trends can be found early — and further deterioration prevented — with rapid mortality surveillance.

2) Protect our health care workers to keep our health care systems functioning so they can prevent both coronavirus and non-coronavirus deaths

It is appalling that more than 100,000 health care workers have been infected with the novel coronavirus. The health and economic consequences of losing health care workers and overwhelming health care facilities are catastrophic.

This does not have to be. I began my public health career documenting and stopping the spread of multidrug-resistant tuberculosis in hospitals; it is possible to make health care much safer.

Singapore has had few if any health care workers infected by the virus at work — not thanks to high-technology interventions, but due to sensible, meticulous attention to protocols. Protective equipment is important, but comprehensive and well-implemented infection prevention programs are the most effective ways to protect health care workers and patients.

Only if health care workers are and are known to be safe will we be able to prevent avoidable deaths from people infected with the novel coronavirus and also prevent increases in mortality from other conditions that result from overwhelmed health care systems.

3) Preserve non-coronavirus health care

In New York City, between mid-March and mid-May, there were more than 4,000 “excess” deaths — deaths that may have been but are not known to have been related to the coronavirus. It’s likely that many people died from non-coronavirus causes because they did not seek care, for example for heart disease, which is the leading cause of death in the US.

Avoiding an increase in non-coronavirus deaths is a particularly urgent priority in Africa. If we don’t take steps to preserve care, over the coming years more than 10 million people in Africa could die from malaria, tuberculosis, HIV, vaccine-preventable diseases, and other causes due to the pandemic’s disruption of health care systems. Yet the age structure — only 4 percent of Africans are over age 65 — means that the proportion of coronavirus infections that are fatal will be far below 1 percent: closer to the seasonal flu than to the devastation seen in other parts of the world.

If we fail to preserve the programs that address preventable killers, the number of people who die from the coronavirus directly might be a small fraction of those killed by other diseases because of the disruption the pandemic causes. Donor agencies, international organizations, and governments themselves must keep non-coronavirus health care going, with telemedicine, longer-term prescription refills, safer facilities, and bolstered primary and preventive care.

4) Protect the most vulnerable

One-third of the US coronavirus deaths have occurred in nursing homes, revealing that facilities for the elderly will be coronavirus death traps until we drastically improve efforts to keep the virus out, find it fast when the first staff or residents become infected, and stop outbreaks from spreading.

The US Centers for Medicare and Medicaid Services (CMS) has made a good start requiring an end to nonessential visitors, but regulators, payors, and nursing home administrators will all need to keep the virus out with strict policies. These include universal wearing of masks, limited visitors, and extensive testing. Nursing homes need to find the virus fast with rapid and repeated testing, and they need to stop outbreaks before they spread widely with rapid-response teams and test-based strategies. We need to identify and protect the highest-risk facilities — not just nursing homes, but also prisons, homeless shelters, and factories, and the highest-risk individuals, including the elderly and those with underlying conditions.

5) Balance saving lives with preserving livelihoods

Health versus the economy is a false dichotomy. Poverty increases ill health, and until people are confident, they will not resume economic activities.

Yogi Berra asked, “If people don’t want to come to the ballpark, how are you going to stop them?” Unless people feel safer working, dining, or shopping, they won’t venture out for those activities.

The coronavirus will cause the first increase in global poverty in more than two decades. In a recent survey in Africa, half of respondents estimated they would run out of money and food in a week or less.

Every country needs to find the balance, and this may mean allowing economically important activities to begin even before all of the ideal disease control systems are in place. This can only happen if we better protect health care workers, shield the most vulnerable, and redesign to reduce risk. In most places, most economic disruption from the pandemic isn’t from lockdowns, but from fear — much of it rational — that everyday activities could kill us or our loved ones.

It’s not a “guns or butter” dilemma. We can save the most lives and protect our economy most effectively by urgently strengthening public health and emerging as soon and as safely as possible, focusing on the most important societal activities first. This means widespread use of face masks, hand-washing, staggered shifts, telework, and prompt contact tracing to prevent cases from becoming clusters, clusters from becoming outbreaks, and outbreaks from forcing another retreat into our homes.

The British epidemiologist William Farr wrote, “The death rate is a fact; anything beyond this is an inference.” Weekly mortality tracking can guide a response that rapidly identifies and prevents further increases in coronavirus and non-coronavirus deaths. Only focused and intensive action will prevent another 100,000 deaths in our nursing homes alone.

As future waves of the virus hit, we need to be ready to adapt rapidly to reduce spread, stop outbreaks, and protect the vulnerable. In every step we take, we must first remember: Illness and economic damage are reversible. Death is not.

Tom Frieden is a senior fellow for global health at the Council on Foreign Relations, CEO of Resolve to Save Lives (an initiative of Vital Strategies), former director of the US Centers for Disease Control and Prevention, and former commissioner of the New York City Health Department. Follow him @DrTomFrieden on Twitter and Instagram.

7 potentially deadly errors the US is making in its coronavirus response

2020-03-17T16:08:04-04:00

A man reads a coronavirus prevention tip on March 15, 2020 in New York City. | Cindy Ord/Getty Images

As the Covid-19 pandemic continues to spread rapidly, every step of the response needs to prioritize actions most likely to achieve three overarching goals: prevent infections, prevent infected people from dying, and reduce societal harms.

But the United States’ response is being undermined by seven potentially deadly errors.

1) Testing is not a panacea

There is understandable frustration and outrage that testing has been slow and often inaccessible in the US. But lack of testing has led some to miss the point of what tests can — and cannot — do.

A surge in people being tested could actually spread disease, because people can become infected by someone else waiting to be tested. Getting tested today is no guarantee you won’t get infected tomorrow — and may give you a false sense of security. Furthermore, emerging data suggests that testing of throat swabs may miss as many as two-thirds of infections.

From my point of view as an infectious disease control physician, it’s dismaying to see both the promises of and demands for widespread testing that, if met, will do little good and possibly some harm. That said, in some contexts testing is absolutely, crucially important:

In areas with few or no cases, to inform containment and isolation strategies and facilitate contact tracing. Seattle would likely have had a much smaller outbreak if testing there had been widely available sooner.
In areas with community transmission, to inform treatment and protection of vulnerable groups, especially when there are outbreaks in hospitals, nursing homes, homeless shelters, and prisons.
In health care facilities treating severely ill patients, to identify those with Covid-19 in order to improve infection control, know when it is safe to discharge patients, and identify participants in clinical trials. For these reasons, every patient in the United States with severe pneumonia should be tested for SARS-Cov-2 infection.
For epidemiological investigations, to determine how widespread infection is, facilitate surveillance, and inform situational analysis, projections, and investigations, including into how the virus is spreading and how infectious asymptomatic people are. The Centers for Disease Control and Prevention’s initiative of testing for the virus in all patients with influenza-like illness at outpatient health care providers is essential to help understand where the virus is spreading, to whom, and what the trend will be in the coming weeks and months.

In areas where the virus is spreading, there is little benefit, and some potential harm, to testing individuals with mild or no symptoms. In the process of getting tested, these people will take up the time, protective equipment, and lab materials of health facilities. If they’re not infected when they travel to and get care, they may get infected in the process.

This is less of a concern for parking-lot, drive-through testing in the private sector, but whether people with symptoms are positive or not, they must isolate themselves, especially from medically vulnerable people: The test could be falsely negative, or could become positive the next day. Furthermore, in a community-wide outbreak, there’s no way public health workers will be able to identify and track contacts of all people who test positive.

The larger problem is not the limited value of testing of mildly ill patients. It’s the distraction from what’s most important. Just as the CDC was distracted from its core activities by cruise ships and dealing with repatriating travelers to the United States, the urge to test is distracting much of the US response from the actions that can save the most lives. Which brings me to the single most concerning error:

2) We’re not getting and disseminating answers to key epidemiological questions

This is the most important thing we’re not doing right now. There is so much we need to know in order to make better decisions about what to do. We need to know who is most likely to die from Covid-19. We know that older people and those with underlying health conditions are at greater risk. But we don’t know at what age risk actually increases. We don’t know which medical conditions may be riskier than others. Over 60? Over 80? Which underlying conditions? Controlled diabetes? Hypertension? On certain medications?

If we know this, we can give better advice: whom to tell to become “semi-hermits,” and whom to test even if they are only mildly ill. And we don’t know the answers to other key questions that determine policy decisions. Can children, who don’t seem to get severely ill with Covid-19, spread the disease? How is Covid-19 spreading in hospitals and other care facilities, and how does this affect health care worker safety and infection control procedures?

Although the virus can persist on surfaces, is it common for people to get infected from contact with contaminated surfaces, and how does this change the need for environmental cleaning — or reduce it? Answers to these questions are essential to guiding rational, effective action. If the studies are being done, they need to be accelerated and published. If not, they need to start, today.

3) We’re not preparing adequately for a surge in cases that could overwhelm our health care system

If there are too many cases at one time to allow effective care, patients who could be saved will die and infection will spread to patients and health care workers, as occurred in Wuhan, China, and in northern Italy. There’s a need for more protective equipment for health care workers, and we’ll need to explore use of newer technologies including reusable respirators.

Even though we have increased the number of ventilators in the Strategic National Stockpile severalfold, in a worst-case scenario, we wouldn’t have the hundreds of thousands we’d need. Every hospital needs to come up with a plan now to double or triple its intensive care capacity.

New modeling and experience suggests that the increase could be as much as a 10-fold increase or more. Drastic measures are needed. China built a 1,000 bedded hospitals in 8 days; we must do as much as we can to care for as many patients as we can as safely possible.

We should be starting to distribute supplies from the stockpile to get the kinks out of the system. And we should be planning for the awful possibility that we may need to construct MASH-type intensive care units. This is why we are now urging social distancing measures that seem extreme: By reducing disease spread, we can “flatten the curve” so that the cases we will inevitably see are spread out over time and don’t overwhelm the health care system.

4) We’re not assessing the costs and health benefits of specific social distancing interventions

It makes perfect sense to wash hands, cover coughs, stay home if ill, and stop shaking hands — and it’s all free. And we will have to telework, cancel meetings and sporting events, and consider ways to decrease potential contact on subways and buses.

But closing all schools may not make sense right now. Unless there is documented widespread community transmission — something we’re not yet seeing in most of the country — there is no need to close schools. An interim intervention is to allow schools to remain open but require them to enable online options for teachers and students who are medically vulnerable. We must consider the huge societal costs of closing schools against what may be little or no health benefit — particularly if kids continue to go out and are increasingly cared for by grandparents and others who are vulnerable.

What if parents are needed at health care facilities, or utility plants, or to provide other essential services? Where will those who depend on meals provided at school get food? In influenza, closing schools for months may reduce spread by up to 40 percent. But we don’t know that there will be any decrease in spread of Covid-19 from closing schools.

5) We’re not effectively communicating risk

Many young people are terrified, while many older people seem to be taking a business-as-usual approach. This is not the end of the world, it’s not the zombie apocalypse, we’re not all going to die.

Most people who get Covid-19 have mild, moderate, or no symptoms, and approximately 99 percent recover. Yes, this is the most disruptive health threat since the influenza pandemic of 1918. And, sadly, many people are still going to get sick and some will die. We need to focus our attention on preventing our most vulnerable people from infection and providing safe, excellent care to those who become severely ill.

6) Public health professionals at the CDC and elsewhere need to speak with the public every single day

There have recently been attacks on CDC and inaccuracies about what it has done. CDC did have an initial problem with public health laboratory tests.

But it remains a wonderful organization with 20,000 staff dedicated to protecting and improving health. It has some of the best health experts anywhere in the world, and is the single best source for information on the pandemic. The public will be best served if we hear directly from CDC’s top experts every day. This is especially important because we are learning more about the virus every day and need definitive information.

7) Partisanship

Whatever your view of the current administration, some of its actions have saved lives. The ban on travel from China undoubtedly reduced the number of Americans who became infected with Covid-19. The new ban on travel from the EU could have some benefit — but only if we understand that this delays disease spread and does not prevent it, and is justified only if we use the time it buys to follow the first six steps above.

Presidential attacks on the CDC and misrepresentations of past actions can undermine the ability of society to respond effectively — public health should be a nonpartisan space. President George W. Bush advanced pandemic influenza planning. President Obama oversaw effective responses to H1N1 influenza and Ebola, and created the Global Health Security Initiative to begin building the systems to address exactly this type of health event.

Partisanship has no place when lives are at stake. Covid-19 might even help all of us realize that we are all connected, and although we need to increase social distance, we also need to increase solidarity to help each other get through what has quickly become a national and global crisis.

Dr. Tom Frieden is the former director of the US Centers for Disease Control and Prevention and former commissioner of the New York City Health Department. He is president and CEO of Resolve to Save Lives, a global nonprofit initiative funded by Bloomberg Philanthropies, the Chan Zuckerberg Initiative, and the Bill and Melinda Gates Foundation and part of the global nonprofit Vital Strategies. Resolve to Save Lives works with countries to prevent 100 million deaths and to make the world safer from epidemics. Frieden is also senior fellow for Global Health at the Council on Foreign Relations. Find him on Twitter @DrTomFrieden.