COVID-19: Can we “open the economy”?

On March 13 I sent a message to you all saying that we were going to close our practice to routine visits. This was a big step for us because the comprehensive physical that we do for patients is core to our business. We want to learn as much as we can about you so we can best advise you on your health. Health isn’t reactive, it’s proactive. And throughout the COVID pandemic, we at Harper Health have worked hard to be proactive with our recommendations for you.

As we think about the transition from Shelter at Home to some version of “normal”, what are the factors we need to be considering? Well first, we need to remember why we are sheltering at home in the first place. Back in February the virus started spreading between people (not just in travelers) in multiple hot spots across the country. In March the decision was made to limit person-to-person contact as much as possible to slow the spread. If we slowed the spread, then we could prevent our hospitals from being overwhelmed with patients. This is beginning to bear fruit, as we hear that our city and state may have flattened the curve.

Does that mean we’re safe? Theoretically, if we had a full lockdown in the US, where no one was interacting with anyone, after about two weeks those who were infected prior to the lockdown would get sick and go through their illness. After a month or so, anyone who could get sick would get sick and the virus would then disappear because the virus needs a host. In order for it to survive, it needs to grow inside someone. So, if the virus dies out, and we completely close the borders and prevent the disease from coming into our country over land, sea, and air, we’d be good. Is this reality? No. We haven’t been on full lockdown, people are still interacting with each other. We can’t and would never close our borders to travel both in and out of our country. The virus will be in our communities. Period. We’re still at risk.

Yes, a very large percentage of us are doing our part but it’s not enough to eliminate the virus. Our actions so far have been meant to mitigate the effects, which is different than containment. Mitigation means trying to lessen the effects. Containment means identifying and isolating all of the infected.

As I mentioned in an email four weeks ago, I believed there were five key outcomes we should aim for as we Sheltered at Home. Others wrote about this in the same way. These were my five:

1. Build up supplies

2. Develop successful treatments

3. Establish herd immunity

4. Delay the community impact

5. Develop a containment strategy

How are we doing? Supplies? This still seems to be a serious struggle. Treatments? Studies are ongoing but nothing in the past four weeks has solidified a strategy for prevention or early treatment. We’re still pinning hopes for hydroxycholoroquine, but studies are still ongoing. Novel drugs and convalescent plasma are being studied right here in Chicago. Herd immunity? The goal is to get at least 60% of the population infected and immune before it becomes difficult to spread the virus. To know this we need to be testing people. We’re still woefully behind on that. We’re also not even sure what level of immunity people get after they’re infected. Delay the community impact? We have done that, which has gotten us one month closer to a vaccine, but the vaccine is still a long way off. Containment strategy? Different state consortiums are being established to plan for this. I suspect the Midwest will develop one, as well. The smart folks at Johns Hopkins University have put forth a plan. We need to be EXTREMELY thoughtful about how we emerge from our homes.

If we assume that we have successfully mitigated the damage from this first wave of infection—if you can call over 25,000 American souls lost so far a success—we need to go back to what we should have done at the beginning. Containment. What does containment mean? Some of you may remember the first Illinois couple to be diagnosed with COVID-19 at the end of January. They had come back from Wuhan, got sick, were diagnosed, and then isolated at home. The Illinois Department of Public Health tracked down all of their contacts, quarantined them, and assessed them for infection. In the end, the infection was contained to just those two people. It was a coordinated effort between cooperative patients, contacts and public health workers. As we emerge from our homes, if we want to prevent a serious second wave we need to be doing something similar. Here are some of my thoughts.

1. We need to test not just people with symptoms and their contacts, but asymptomatic people need to be tested, too. The frequency and intensity of testing should be directed by public health experts in areas where the illness has a particular prevalence. We can’t let hot spots grow, as small community hospitals can quickly be overrun

2. People who test positive for active or early infection need to be fully isolated. If their housing situation doesn’t lend itself to isolation, then free housing in a local apartment or hotel should be provided for them

3. Close contacts of people who test positive must be fully isolated as well, and tested until the incubation period is over. If at any point they test positive, their own contacts then need to be tracked down. Hopkins estimates that 100,000 to 200,000 folks will be needed to do this surveillance work. There are millions of newly unemployed so I’m sure we can find the people to do this

4. The rules about how we behave in public and at work must be changed. I don’t have the answers to these, but a science-based strategy needs to be developed. Here are some SUGGESTIONS:

• Universal cloth mask use. If you still need one, let us know. As supplies of masks change, I suspect the recommendations on recommended types we should use will change as well

• New rules on restaurants. Servers wearing masks? Tables six feet apart? Bring your own utensils? Clean the utensils at the table? People need trust that they are safe in restaurant environments

• New rules on the workplace to limit casual person-to-person interaction. Either alternating weeks where staff is onsite or moving to day and swing shifts to limit the number of people in the office at once

• New rules on business meetings. The virus lives in tiny droplets in between folks who are having a conversation. A cross breeze may disperse these droplets. What do we do if there are no windows in our offices to create these cross breezes?

• New rules on sports. Until I am immune to SARS-CoV-2, I will not feel comfortable in a crowded football or baseball stadium or hockey arena. Until we have proof that infection grants immunity, I wouldn’t fill college football stadiums with rabid fans. It is true that people can choose to accept that risk, but unless there is a comprehensive surveillance strategy, those newly infected people will just spread it among their communities

There is so much yet to be figured out before we can safely emerge from our homes. It's easy to be impatient; I am as well. Yet I actually have confidence in our state and city governments that they are giving this good counsel and we will emerge as a community in a thoughtful way. A lot happens in a day, in a week, in two weeks when Illinois Shelter at Home order is supposed to end. I will share our thoughts as we know more.

More to come.

Dr. Will