The Coronavirus ‘Plan for a Plan,’​ Plan

Only in a world of ideologues and demagogues, of propagandists and Internet trolls, are our options limited to: “send everyone back to the world by some arbitrary date, and never mind the body count” versus “everybody’s grandparents in coronavirus lockdown until many of them die of other causes before ever again hugging their grandchildren.”
Two medical workers in full protective gear, with blue gowns, blue gloves, masks and hair covers, point a swab towards the driver side window of a car to test for Coronavirus.

Of course there is another way.

The other way begins with the only immediate option any of us has: following the current rules. Whatever the ultimate toll of pandemic coronavirus proves to be, however much more or (almost certainly) less than other more familiar adversities, its particular danger lies in concentration. Anything that makes many more people acutely ill in a given place at a given time can overwhelm medical systems not proactively built with considerable surge capacity. When it comes to public health in the United States, all we ever seem to do proactively is hobble it- then expect it at full gallop the moment trouble arrives.

This trouble was predictable, even inevitable- a pandemic was always coming. This has been a refrain in the writings and rants of every public health expert sharing public commentary for years, myself included. The warnings, of course, were ignored if not derided, much as warnings about lifestyle and health are all too often ignored by individuals until after the MI, or stroke.

Options are always less good when forced to treat what may have been prevented, and here we are. So yes, please: practice social distancing. Shelter in place as instructed.

But that is not a plan; that’s just one step up from a reflex. We can’t hunker in place with anxiety and worry, and little to do other than track coronavirus stats as if rubber-necking a slow-motion highway collision, indefinitely. That is shallow, callous, and costly in every currency conceivable, most importantly- human suffering.

Even as we follow the current rules, we all want to know that those in charge are right now asking, and then working to answer, and then devising a detailed plan to act on- all the right questions. We want to hear about plans now for planning soon to give us a plan not long after.

What questions? Who is at high risk of severe infection, and who, if anyone, is not? Who, if anyone, can safely afford to get this infection, and get over it, at very high likelihood of full recovery and immunity- and who must avoid it until we have a vaccine and/or highly effective treatment? Does infection always, often, usually, or only sometimes end with robust immunity? What are the prospects for herd immunity as a basis for the “all clear”?

From the start, better data from other countries have indicated that 98-99% of all coronavirus cases are mild, and do not require any particular medical care. From the start, global data have pointed to those under 50 and in good health as at markedly lower risk of severe infection than others.

But here in the U.S., we began hearing early about hospitalizations in young people; and are now hearing more about that daily. I don’t know what it means, and neither do you.

There are two possibilities, but before I explain them- I want to send my deepest condolences to every individual and family in this group. Whenever it’s you, or someone you love, who really gives a damn what the statistics mean? The greatest liability of public health is its focus on something that doesn’t really exist: a public. The public is you and your family, me and mine, and everyone else’s and theirs. Facing the facelessness of public health, lost behind a veil of statistical anonymity, and seeing the pained faces there is always essential, and especially now.

Yet, the numbers matter if we are to understand patterns, and we don’t have what we need as of yet. For example, we will hear that hospitals in a given state have just admitted N people over 50, and N people under 30, for coronavirus treatment. The headlines, of course, are that “50% [N/2n] of coronavirus hospitalizations are in those under 30.” I have long known the media mantra “afflict the comfortable,” and my friend John Tesh recently reminded me of another: if it bleeds, it leads. This is a bloody headline afflicting the relative comfort of thinking that there are somewhat stable risk differentials for severe infection- that our children are less vulnerable.

There is valid reason to worry that in America, young people are not at the same, much reduced risk of severe infection as in other countries, namely, the generally poor state of our baseline health. Obesity is apparently a risk factor for severe coronavirus infection, and type 2 diabetes even more so. Our long-standing neglect of lifestyle as medicine has been costing us years from lives and life from years perennially, but it may now append the insult of acute threat to that long-standing injury. If that is the case, our coronavirus losses may be greater, and our risks less varied, than elsewhere in the world.

But there is another quite plausible explanation.

Imagine, for instance, that N = 100. Now imagine that – if we had the data- we would know that in that same state, there are 1000 total people over age 50 currently infected; but there are 250,000 people under age 30, many of whom acquired the virus on some large college campus before being shipped home. Well, then, although 50% of hospitalizations [N/2N] are indeed among those under 30, the risk of hospitalization among those under 30 is 250x less than for those over 50 (i.e. the risk of hospitalization for someone under 30 would be 0.04%). You don’t make it through Epidemiology 101 without learning to ask, “what’s the denominator?” (or, in other words: out of how many?) – and for most of what matters most to our understanding of coronavirus, we don’t yet know.

As we hunker with our families and do all we can to mitigate viral spread right now so that medical systems around the country can manage the demand, we should be hearing that these questions are being asked. We should be hearing about plans to get them answered, and some reasonable timeline projections. Dr. Fauci has said that the virus will dictate timelines, and while right in important ways, it is- if I may say- a bit too passive. Really, it is our understanding of the best ways to minimize total harms that will guide our actions and the timing of them, and understanding need not just come in the fullness of time; we can mobilize the teams to go out and get it.

As an example, since my OpEd on these topics appeared in the New York Times, I have had at least 6 independent groups of experts in mathematical risk modeling send me their detailed work on coronavirus. All show marked reductions in total net harm to people with a risk-stratified (vertical) approach to viral interdiction. But these models are only as good as the data flowing into them. I have introduced all of these experts- from places like MIT and Carnegie Mellon- to one another, and they are now working together. I am doing all I can to help connect them to better data sources and the authorities who can best leverage their efforts, too. The timeline for a plan depends on just such effort, in my view.

I think of my 80-year-old mother, equally worried right now about two things: that she might get coronavirus and die, and that she might die of something else during indefinite lockdown before ever again hugging her grandchildren. She, and every other grandparent and older parent out there- and the rest of us, for that matter- deserve the comfort of knowing there is more to it than that. We deserve to hear, now, that planning for the best ways to mitigate the many potential means this all has to destroy and take lives- is well under way. I think many would even better practice the current restrictions knowing there is something in the works to follow.

In his open letter to the president, Tom Friedman said we need a plan. Indeed we do, and soon. But we should not ask anyone prone to choke on the nuance a true plan would require to bite off more than they can be expected to chew. Adversity is teaching us patience; we can get there in steps. Right now, I think most of us would settle for knowing there is a plan-for-a-plan, plan.


This article was first published on LinkedIn.