A COVID-19 Conversation with Stanford epidemiologist Dr. Steve Goodman
A few days ago, I traveled to Boston to pick up my son from college. School officials had emailed several days earlier ordering all students to leave campus due to the threat of COVID-19. We were informed that classes would be held online for the duration of the school year.
The normally bustling college quad was eerily empty when I arrived. Stray students wandered about looking shell-shocked and disoriented. Cars piloted by parents pulled up to the dorms and students quickly loaded duffels and suitcases containing the contents of their lives. Soon-to-be-ex-roommates hugged, a few elbow-bumped, and some cried softly.
“It’s like the apocalypse,” my son said glumly in his dorm room, which looked like it had been ransacked. He and his three roommates were in various stages of packing. The rapid unraveling of this tight-knit community was disorienting and upsetting. They were joining a global wave of pandemic exiles.
I turned to my older brother to make sense of the extreme measures being taken to contain the COVID-19 pandemic. Public health is his wheelhouse: Dr. Steve Goodman, MD, MHS, PhD, is an Associate Dean at the Stanford School of Medicine, where he is also a Professor of Epidemiology and Population Health, and Medicine.
A week ago, Steve joined me as a guest on The Vermont Conversation, a public affairs radio show that I host. The podcast and Medium article from that conversation, “An Impending Catastrophe,” went, well, viral.
I asked Steve to continue our public conversation to bring us up to date. This is adapted from our discussion on March 18, 2020 on The Vermont Conversation.
Coronavirus has now been confirmed in all 50 States. Here in Vermont, the number of cases jumped ten-fold in just a week, and the first deaths have just been reported. Globally, thousands of people have died and extreme measures have been implemented throughout Europe and in many other places. What have we learned about coronavirus that we didn’t know when we talked a week ago?
As you might imagine, the research and the numbers are literally pouring in. In the few days since we talked there are multiple papers and analyses that have told us both what we might be facing and what we have to do.
Two important studies came in over the weekend. One was a modeling effort from the UK that showed what would happen using different strategies to manage the outbreak.
Another was a paper published in Science with a terrific analysis of the Chinese data that found that 86% of the virus transmission early in their epidemic — before they took what we would consider to be draconian measures — was from asymptomatic or minimally symptomatic cases. That is huge.
What is the significance of this?
It means that a high fraction of infections are coming from people who have no idea that they are infected. Which means that you can’t organize a strategy around isolating only people who are showing symptoms. You have to test!
Let’s talk about the British study that did the modeling of the various types of disease control in the US and Great Britain. What did that tell us?
This was a very sophisticated model that looked individually at case isolation, household quarantine, closing schools and universities, social distancing, and then all of them together. What this showed was that the peak of the epidemic, if they do nothing, would be roughly three- to fourfold bigger than if they impose all those measures. They’re modeling the peak of the epidemic occurring in mid-June. They also calculated if and when Great Britain would exceed the capacity of its ICUs. Sadly, that occurred in all scenarios, with the peaks being many times above their capacity. That was a little depressing.
So no matter what Great Britain does, it will exceed the capacity of its healthcare system?
That is what they’re saying right now, yes. The US has more ICU beds per capita, but still below the peaks they predicted, and how many will be available for coronavirus patients is still uncertain. Those results are consistent with a recent Harvard paper warning that US ICU capacity could be exceeded in many regions.
Everyone is talking about “flattening the curve,” meaning keeping the number of infections below the line where the healthcare system can deal with it. So what happens if you exceed that line?
Well, we’re seeing what happens in Italy. And we saw it in China, which is that there are people sitting in the hospital who need very intensive respiratory or physiologic support and they can’t get into the ICU where they have ventilators and can get that support. That’s why ICU capacity is so important; at that point it is life or death. If you need a ventilator and can’t get one, you will probably die.
The health care system capacity is very closely related to the fatality rate from the disease. If we exceed the capacity of the ICUs or of our ventilator stocks, then people whose lives could have been saved will simply start dying. And doctors will be put in a completely impossible position of having to choose who’s worth saving. This is what has happened in Italy. And that’s the situation we could find ourselves in.
As we look around the world, what is working best?
This is the billion-dollar question right now. We know that the Chinese efforts worked both in cities early in the epidemic and in Wuhan where it was out of control — but their efforts were extreme. They involved measuring temperatures and testing huge numbers of people, immediately isolating those who had a fever even before they had other symptoms, putting them in what they called “fever camps,” which were special hotels or apartment buildings, and taking them away from their families. There was also complete lockdown of some neighborhoods. By doing this, the spread was minimized and they were able to tamp down the peak of the epidemic.
South Korea, on the other hand, moved very aggressively early in their epidemic to develop testing capacity, and then to massively test their population, with isolation and intensive contact tracing of positives. They tested over 50 times more people per million than we have, and they did it early, when it made the most difference.
The severity of the measures needed depends on where we are on the epidemic curve. Every week brings a doubling or more of cases. If we’re very early on the curve, then the kinds of social distancing measures that are now being taken where I live in California — where we’re not supposed to go outside of our home except for essential activities — might have an impact. But we may have started too late, and have to impose yet more severe restrictions.
This is going to be very regional. The places that can learn the lessons from the more severely affected places are the ones that will do the best. Unfortunately, this country did not learn the lessons of Korea, Italy and China — that we must react very quickly. But within our country, hopefully places like Vermont and other regions that are watching what’s happening in Seattle, New York and California can react appropriately and keep their peak at a manageable level.
There has been a big focus on testing. President Trump said several weeks ago that anyone who wants a test can get one. That was not true. What is the reality of testing now? And does testing matter?
Testing matters hugely. Without adequate testing, no strategy will work well. The only way we can know that asymptomatic folks are infected is through testing. The status of testing nationally is very unclear because the CDC numbers are incomplete. But testing is gearing up dramatically, partly because the FDA has officially let both academic and commercial labs within states develop their own tests and proceed with just state regulation without the bottleneck of having to be approved by the FDA. So now you have an army of companies and labs that are gearing up to do these tests as fast as they can.
You’ve told me that there is a shortage of a key chemical reagent. So even if they’re sending out testing kits, they can’t run the tests.
That’s exactly right. The scarce reagent is a chemical that needs to be used in the very first step of the test to extract the virus’s RNA, its fingerprint. There is now a national shortage and research labs and drug companies are being asked to donate their supplies. The company that makes the reagent is gearing up, but it’s unclear whether they can meet the demand for millions of tests. Even though there are lots of kits being sent out by the CDC, these tests actually don’t include this reagent.
That’s like getting a bookshelf from Home Depot and finding it has no screws.
Right, or dry soup mix from the store, but you don’t have water to add.
Let’s talk about “what could have been.” We first heard about a coronavirus outbreak in China in December, and the first US cases appeared in January. According to POLITICO, President Trump did not want to do widespread testing for fear that it would hurt his reelection. Can you sketch out the alternative scenario for how the coronavirus pandemic could have been managed here in the U.S., and where we might be today if that had happened?
The actual response to something like this takes massive advance coordination and planning.
When Trump’s team first came in, there was a White House exercise with administration officials from the Obama and Trump administrations that exactly mimicked a pandemic outbreak such as we’re facing today. Trump’s team was told to be ready for it. Not long after, they disbanded the pandemic preparedness team.
What our response could have looked like was coordination, plus early warning, plus massive early testing and selective isolation. This is exactly what Korea did, which had its first few cases when we did, and they have beaten back the virus.
Trump officials thought that our pandemic response could all be constructed afterwards. In fact, President Trump said that the pandemic response people were fired because they were sitting around doing nothing and could always be hired back if a problem arose.
Well, we have fire departments, right? We don’t start talking about hiring firefighters as soon as we see a massive fire. But that’s what we’re doing now.
What could we have done? We could have had the firefighters in the White House and at the CDC and in public health departments with networks and systems ready to go from the first day. We didn’t have that.
So guess what? The house is burning down.
What could have happened? It’s hard to say. But we wouldn’t be trying to fight this fire while it’s roaring, with blindfolds.
Disasters like this are a time when normal thinking and acting ends and society can take quantum leaps in a different direction — hopefully for the better and not for the worse. These can be times for big ideas. What is a big idea for how we could reshape how we do healthcare and public health in this country? This could be the silver lining of this pandemic.
Public health functions are done at the local level. Health departments are typically starved for funds. They barely have enough people to carry out even the minimal functions of those departments, no less connect on a regional and national level to respond to emergencies and to the huge public health problems that we face.
We think that we’re powerless against these plagues. But we’re not. A robust public health infrastructure is a great defense. Now we’re seeing the price of not having one.
The CDC has also been cut to the bone. It’s very dispiriting to hear that even in the face of this pandemic, the Trump administration was just last week justifying another 15% cut to the CDC. That’s our national public health agency. They are our firefighters.
What we need to do once we get through this is to have a much more robustly funded and coordinated public health infrastructure at the local, state and national levels. I hope we still have the resources left and political will to do it.