Pandemic Is Overwhelming U.S. Public Health Capacity In Many States. What Now?

Jul 28, 2020
Originally published on July 29, 2020 12:48 am

When the coronavirus pandemic began, public health experts had high hopes for the United States. After all, the U.S. literally invented the tactics that have been used for decades to quash outbreaks around the world: Quickly identify everyone who gets infected. Track down everyone exposed to the virus. Test everyone. Isolate the sick and quarantine the exposed to stop the virus from spreading.

The hope was that a wealthy country like the United States would deploy those tried-and-true measures to rapidly contain the virus — like quickly dousing every ember from a campfire to keep it from erupting into a forest fire.

Today, that hope has been extinguished — not the fire. A return to more restrictive shutdowns of businesses and public gatherings is likely necessary in many places, public health leaders say, to bring the number of cases low enough that "test, trace and isolate" can be used to douse epidemic embers.

"Right now we are experiencing a national forest fire of COVID that is readily consuming any human wood that's available to burn," says Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota.

Testing, contact tracing and isolation are the tactics being used successfully to crush outbreaks in countries such as South Korea and Germany. But those places never had the level of case surges that many U.S. states are now experiencing.

"When you have something like this happening, there's no way that traditional testing and tracing is going to have any meaningful impact," Osterholm says. "I liken it to trying to plant your petunias in the middle of a Category 5 hurricane."

Others agree. At this point, there are just too many new infections occurring too quickly for underfunded, understaffed public health departments to effectively use testing and contract tracing, according to Dr. Jeffrey Engel, the senior adviser for the COVID-19 response for the Council of State and Territorial Epidemiologists.

"It's just this massive effort," he says. "It's just not feasible."

That has become especially true because of the long delays in getting the results of coronavirus tests, which can now take days or even weeks because of the surge in demand for testing. By that time, anyone who's infected could have already spread the virus to other people.

"I think it's the right response when you have a nearly controlled epidemic and you're trying to mop up the spills. But we're not there in most places," says Marc Lipsitch, a professor of epidemiology at the Harvard School of Public Health. "In many places, I think, we're engaging in collective wishful thinking."

Another problem is that test results in the U.S. often don't include basic information needed to find people who test positive, such as phone numbers and addresses. And even if public health workers can find infected people in time, it's often difficult to persuade their contacts to quarantine, Engel says.

"It's voluntary. And they have other things to do," Engel says. "They may be essential workers. They may need to get to work. Life takes over."

So if testing, contact tracing, isolation and quarantine won't work, what will?

"Given our basic failure to fix the gaps in testing and the bottlenecks, that really puts us on a path where there is no viable alternative beyond shutdowns," says Jennifer Nuzzo, a senior scholar at the Johns Hopkins Center for Health Security.

Now, Nuzzo doesn't think all hope is lost. If enough people finally start wearing masks, and get vigilant about staying at least 6 feet away from other people, especially indoors, there may still be hope in at least some places of avoiding new shutdowns, she says.

"I do really worry about forcing an entire state or country to retreat to our homes for extended periods. These are harmful measures in themselves," Nuzzo says.

And there may still be some places where the virus may not have yet spread widely, or has been suppressed low enough, for testing and contact tracing to be effective, some say.

"Hawaii!" wrote Caitlin Rivers of the Johns Hopkins Bloomberg School of Public Health, in an email to NPR. "They have the advantage of being an island, though."

Massachusetts has also built an effective public health workforce, she notes.

And in places that can't avoid new shutdowns, some hope they won't have to be as draconian as the first time. Outdoor spaces — such as parks, playgrounds and beaches — could remain open, for example, as long as people wear masks and maintain 6 feet of physical distance from anyone outside their household.

"We know more about the virus and how it spreads now then we did in the spring," says Rivers. "So, I think, for jurisdictions that take steps backward toward closing — I don't think it will have to look like it did in the spring."

Other scientists have proposed that lockdowns could be avoided if 95% of the U.S. population would start to wear masks consistently in public. But currently mask usage is much lower than that. And some public health experts doubt masks alone could be enough.

"The degree to which masking will drop transmission has been unfortunately overstated substantially by a number of people," Osterholm argues. He points to Hong Kong, which has a big surge despite widespread masking.

"Use masks. They're a complementary part of our response. But they're not going to get us to the level where we can control this virus," Osterholm says.

Now, none of this means testing and contact tracing is useless, experts say. Far from it. Indeed, experts say they want to see it continued and expanded. It can be used strategically to determine how to target shutdowns more selectively in situations and locations where the virus is spreading the most. For example, specific bars where people frequently infect each other can be identified and closed.

Osterholm hopes more measured lockdowns may work in some places too. But he's skeptical, especially about the hottest of the hot spots.

"If we want to be like other countries in the world that have successfully contained the virus, then we have got to take the medicine now," Osterholm says.

"We will not get there unless we bring this virus level down again. And there's just no other way to do it literally but a kind of second lockdown," he says. "And this time let's get it right."

That could knock the virus back enough to let schools safely reopen, get some people back to work, and give the nation time to hopefully, finally get enough tests and hire enough contact tracers. It could help the U.S. get off the current roller-coaster of case surges and regain as least some version of normalcy.

"Those countries that were on fire last spring and then did a lockdown are now the ones that have been successfully reopening," Osterholm says. "Their economies are back, they're enjoying life — and they're still maintaining control over the virus."

Copyright 2020 NPR. To see more, visit https://www.npr.org.

STEVE INSKEEP, HOST:

Now here's a big question - is it time for a new strategy against the pandemic? It's out of control in many parts of the country. Almost 150,000 people in the U.S. have died. And experts say it may be too late to rely on testing, contact tracing and quarantining. Here's NPR health correspondent Rob Stein.

ROB STEIN, BYLINE: When the pandemic began, public health experts had high hopes for America. After all, the U.S. literally invented the tactics that have been used for decades to quash outbreaks around the world - quickly spot everyone who gets infected, track down everyone they might have infected, test everyone, isolate and quarantine to stop the virus from spreading by quickly dousing every ember from a campfire to keep it from erupting into a forest fire. Today, it's that hope that's been extinguished - not the fire.

MICHAEL OSTERHOLM: Right now we are experiencing a national forest fire of COVID...

STEIN: Michael Osterholm is an infectious disease expert at the University of Minnesota.

OSTERHOLM: ...That is readily consuming any human wood that's available to burn.

STEIN: So that strategy that everyone hoped would prevent a viral conflagration by relentlessly testing, tracing, isolating and quarantining, it's just too late.

OSTERHOLM: When you have something like this happening, there's no way that traditional testing and tracing is going to have any meaningful impact. I liken it to trying to plant your petunias in the middle of a Category 5 hurricane.

STEIN: But why? Why is it too late? I asked Dr. Jeffrey Engel that question. He's at the Council of State and Territorial Epidemiologists. They're on the front lines of fighting the virus. I got this beleaguered, almost resigned response.

JEFFREY ENGEL: It's just this massive effort, you know? Test, test, test, test and quarantine and contact trace. And, you know, it's just not feasible. So...

STEIN: Because there are just too many people getting infected too fast now. There still aren't enough tests, so it can take days to get results. By that time, anyone who's infected probably already spread the virus to who knows how many other people, and half the time the test results don't even include the basic information needed to find them, like phone numbers or addresses. And even if you do get to them in time, Engel says good luck convincing their contacts to quarantine.

ENGEL: It's voluntary, and they have other things to do, like their lives. Whatever the situation, they may be essential workers. They may need to get to work. You know, life takes over.

STEIN: So if that won't work, what now? Well, Jennifer Nuzzo at Johns Hopkins says the short answer is a word no one wants to hear.

JENNIFER NUZZO: Given our basic failure to fix the gaps in testing and the bottlenecks, that really puts us on a path where there is no viable alternative beyond shutdowns.

STEIN: Now, there may be some places where there still isn't a lot of virus that could avoid shutting down, but Nuzzo says probably not many. But Nuzzo hopes the shutdowns won't have to be as draconian this time and can at least be less dramatic in some places than others.

NUZZO: Because I do really worry about forcing, you know, an entire state or country to retreat to our homes for extended periods. These are harmful measures in themselves. They may be necessary, but I hope that we can take action to do everything in our power to avoid them.

STEIN: Like finally get everyone to wear masks, stay away from other people as much as possible - especially indoors - and keep testing and contact tracing as much as possible. It is still working in some places and can help target shutdowns at the places where the virus is spreading the most, like crowded bars, where people who've been drinking often end up infecting each other. Michael Osterholm at the University of Minnesota hopes more measured lockdowns may work in some places, too. But in the hottest of the hot spots, he's not so sure.

OSTERHOLM: If we want to be like other countries in the world that have successfully contained this virus, then we have got to take the medicine now. We will not get there. We will not get there unless we bring this virus level down again. And there is just no other way to do it, literally, but a kind of second lockdown. And this time, let's get it right.

STEIN: That could knock the virus back enough to let kids safely go back to school, get some people back to work and give the nation time to hopefully, finally get enough tests, hire enough contact tracers to get off this deadly, miserable roller coaster and regain at least some version of our old lives.

Rob Stein, NPR News. Transcript provided by NPR, Copyright NPR.