By Vivian Ho, Ph.D.
James A. Baker III Institute Chair in Health Economics
Kirstin R.W. Matthews, Ph.D.
Fellow in Science and Technology Policy
Quianta Moore, M.D., J.D.
Fellow in Child Health Policy
As we complete our second full week of working from home, much has changed in the spread of the COVID-19 pandemic and efforts to address it, even though most of us likely feel that too much has stayed the same in our personal lives. Following are some of the sources that we found most helpful in understanding developments in the disease outbreak and efforts to control it.
Epidemiology
If there’s one news item that everyone should see, it’s this graphic published in the New York Times. The link is data intensive, so wait 30 seconds for it to download. The graphic provides the best illustration of how the coronavirus was able to spread so quickly across the world from one food market in Wuhan and the underlying factors that drove the spread.
As of now, we lack sufficient data to accurately predict when the pandemic will peak, and when it will be safe for Houston to lift its mobility bans. The Los Angeles Times reports that Nobel prize winning biophysicist Michael Levitt correctly predicted in January that the outbreak in China would not last for months, if proper social distancing measures were in place. Levitt argues that plateaus in the reported number of deaths and newly diagnosed cases of the disease are often ignored as significant markers of when the situation is likely to improve. However, graphs from the Worldometers website indicate that the daily number of new cases and the daily number of new deaths in the U.S. are still rising exponentially, suggesting that we are nowhere near a plateau.
Researchers from multiple disciplines around the globe are devoting their energies to studying the COVID-19 outbreak in efforts to identify disease prevalence, factors that influence transmission and risk factors for disease severity, and to construct predictive models tracking disease spread. The medRχiv website lists 870 coronavirus-related articles in the pre-print stage, meaning that they are awaiting peer review, but nevertheless are likely to be of interest to policymakers and other researchers. This study conducted by faculty in Philadelphia, Shanghai and Hong Kong is particularly striking in the application of sophisticated statistical modeling combined with detailed health and cell phone tracking data in China. The authors conclude that if Wuhan had not locked down transportation into, out of, and around Wuhan on January 23, COVID-19 cases in other Chinese cities outside Hubei province would have been 65% higher. These findings suggest that the migration of New York residents to other states due to fears of the coronavirus may cause more harm than good in controlling the outbreak.
Researchers are working quickly to provide user-friendly tools to help policymakers fight the pandemic. Researchers at the University of Pennsylvania have built The CHIME (COVID-19 Hospital Impact Model for Epidemics) App, which enables capacity planning for hospitals and public officials by providing estimates of total daily (i.e., new) and running totals of (i.e., census) in-patient hospitalizations, ICU admissions, and patients requiring ventilation.
Policy Response
There has been much finger-pointing and blame by reporters, health care providers, and policymakers in Houston and throughout the country regarding insufficient supplies of COVID-19 tests and personal protective equipment (PPE) for health care providers. The absence of sufficient numbers of ventilators has already reached a crisis stage in many cities, particularly in New York. We do not summarize the articles, because readers are likely to have seen multiple stories on their own.
Readers have likely seen articles such as this one arguing that the economic shutdown to limit the spread of the coronavirus is more harmful than the disease itself. The author of the article argues that more targeted approaches to limit disease spread could be taken. While we agree that more targeted approaches are preferable, we can’t begin to consider targeted options until public health officials have access to an adequate number of tests to determine who is and is not carrying the virus. Former FDA commissioners Scott Gottlieb and Mark McClellan and others have published a Roadmap to Reopening the economy that lists detailed milestones that the federal, state, and local governments should be working toward in order to bring the epidemic under control and reopen the economy as quickly as possible.
We found mention of one study that attempts to weigh the economic costs of the shutdown against the benefits in lives saved. The authors calculate that slowing the economy to limit COVID-19 would reduce deaths by half a million people at a cost of $2 million in lost economic activity per life saved. Weighing the cost in lost economic activity per life saved should be only one input for policymakers when determining when to recommend lifting shelter-in-place restrictions. Policymakers must keep in mind the stress that health care providers are under in the midst of this pandemic. Any decision to lift mobility restrictions when health care providers lack sufficient personnel and supplies to meet the needs of the severely ill could result in collapse of the health care system. In fact, in this NPR segment an MIT economist states that during the 1918 flu pandemic, cities that intervened more aggressively to enforce social distancing actually did better in terms of their economy in the year after the pandemic.
This piece from the Wall Street Journal claims that the January 23 lockdown in Wuhan slowed the virus’ transmission, but still allowed the virus to spread among family members in homes. The reporter claims that Wuhan was truly able to turn the tide only after February 2, when the government shifted to more aggressive quarantine measures. At this point, mild cases and healthy close contacts were sent to makeshift hospitals and temporary quarantine centers. Hundreds of hotels, schools and other places were turned into temporary quarantine centers. If the pandemic continues to grow exponentially in the U.S., it is unclear whether the public would support such aggressive measures to address the crisis.
Within the White House, the Office of Science and Technology Policy (OSTP) has worked consistently to help connect agencies within the administration as well as engage with nongovernmental experts. Working with the National Academies, OSTP requested a standing committee on emerging infectious diseases to gather and disseminate data for COVID-19 research as well as future pandemics. This committee has already released several short papers on specific topics including: social distancing, impact of COVID-19 on younger cohorts, data for modeling and decision-making and survival of the virus on surfaces. Furthermore, OSTP worked with publishers to create a COVID-19 database (CORD-19) that contains thousands of publications, some previous work on coronaviruses and other new articles related to the current pandemic. It has been already noted that decision-making without reliable data can have severe consequences, making access to existing data crucial.
Other interesting discussions related to the pandemic is who controls the intellectual property (IP) for drugs, treatments and preventative measures such as vaccines and how they will be equitably distributed. Already, Gilead Sciences has requested that its experimental drug for COVID-19, remdesivir, no longer be considered an orphan drug, which would have enabled the company to have a monopoly and to block lower-cost generic from entering the market. Clinical trials for remdesivir in the treatment of COVID-19 are just starting, and it’s unclear if the drug will be effective. In addition, the Costa Rican government asked the World Health Organization (WHO) to create a pool to collect patent rights to technologies that would be useful for the detection, prevention, control and treatment of COVID-19. This effort would create universal access to respond more effectively to the pandemic.
Personal Safety
In terms of keeping you and your family safe at home, this article on food safety and the coronavirus was brought to our attention by a friend with a connection working at the Centers for Disease Control. If you’re interested in viewing a safe way to unload your groceries during the pandemic, this video has been making the rounds on social media. One of us is following these measures, and another one of us has decided (unscientifically) that it’s not worth the effort.
On the Medical Frontlines
Reading this piece written by an ICU doctor in Boston brought one of us to tears. We have known for weeks that there would be COVID-19 patients who would be left alone to die. But the reality as described by this physician is heartbreaking. How we hope that marketing professionals will transform this message into a communications campaign to reach those people who are downplaying the need for social distancing, as pictured in Laguna Beach, CA.
The irony is not lost on how a profession once revered by both government and citizens alike for its ability to save lives, treat illnesses and be the frontiers of innovation and science has been left unsupported with major system vulnerabilities exposed. The lack of protective gear for health care workers is astounding, and puts the entire medical system at risk. Health care workers are not easily replaceable, and yet are going to heroic efforts to save patients’ lives and uphold their Hippocratic oaths as demonstrated by this chilling video, which clearly illustrates that physicians lacking adequate supplies are still putting their lives on the line to care for their patients. Moreover, the lack of medical supplies puts critically ill patients at risk, and long-debated ethical questions of the allocation of scarce resources may very soon shift from intellectual debate to a reality that many health care professionals are not prepared to face.
The New England Journal of Medicine has been publishing numerous articles on the coronavirus, some with helpful advice for health care providers on decision-making in times of crisis. This article recommends the creation of a triage committee to determine the allocation of ventilators when there are shortages, which allows the physicians and nurses caring for the patients to maintain their traditional roles as patient advocates. In this model, physicians have the opportunity to appeal the initial decision of the committee when appropriate. Another piece offers six specific recommendations for allocating medical resources in the COVID-19 pandemic: maximize benefits; prioritize health workers; do not allocate on a first-come, first-served basis; be responsive to evidence; recognize research participation; and apply the same principles to all COVID-19 and non–COVID-19 patients.
Conclusion
At this point next week, the number of new cases of COVID-19 may continue to climb exponentially in the U.S. as more test kits become available to the public. We will be watching closely to see whether the number of deaths from the coronavirus climbs exponentially as well. Like you, we hope that the benefits of social distancing will become evident, and that the number of new deaths will start to plateau. On Friday, President Trump signed the $2 Trillion Coronavirus Aid, Relief, and Economic Security (CARES) Act, which includes expanded unemployment insurance coverage to four months and raises the weekly benefit by $600. We hope that most workers will not require four months of unemployment assistance, but it is too early to say. We hope that you and your family continue to stay safe and well informed in these difficult times.