Coronavirus con Tempo: Interdiction Choreography in the Crashing Surf

David L. Katz, MD, MPH, FACPM, FACP, FACLM
LinkedIn
There is no debate, and never was among serious people, about the need to keep those at high risk for severe coronavirus infection and this very nasty germ – SARS-CoV-2- apart. There is only debate about how. Any suggestion to the contrary is misunderstanding, willful or inadvertent, or the replacement of actual ideas with caricatures of them.
Big wave crashing on to a beach

When I first wrote about risk-based interdiction in the New York Times on March 20 (nearly 10 days after I first penned the original version of the column; the time it took for review, revisions, re-review, fact checking, etc.) – it was already entirely clear that letting everyone hazard exposure to this contagion was out of the question. We had abundant evidence from China and South Korea, and burgeoning evidence from Europe those days (lifetimes?) ago – that older people and those with a significant burden of prior, chronic disease were at much elevated risk for severe infection, hospitalization, and death. We already knew that one way or another, that population group, and the virus, had to be kept apart.

The valid questions, accordingly, were: who is at reliably lower risk and who at higher, and how do we best direct our protections preferentially to those who most need them? What data do we need, and how quickly can we get them, to provide these and related answers, and develop policies predicated upon them?

Perhaps one other question might be- “why?”- and that, too, has been caricaturized as if there was some trade-off between lives and dollars in the mix. There never was.

Even though the New York Times put “work” in the headline of Tom Friedman’s column channeling my own, Tom’s focus was not really dollars, but the clearly emphasized social determinants of health. Anyone who has ever touched a toe to the waters of public health knows that social determinants – poverty, isolation, education, discrimination, food insecurity, etc.- exert a monumental effect on the very outcomes we are most concerned about in the midst of this pandemic: severe illness, demands on the medical system, and death.

The premise then, and now, is that coronavirus can kill directly via infection, and can kill indirectly if haphazard interdiction efforts dismantle societal norms, disrupt supply chains, halt the flow of crucial goods and essential services, and propagate such devastation as hunger, depression, addiction, suicide, and violence. A spike in gun sales, and a surge in domestic violence have been documented already – riding the currents born of 10 million unemployment filings.

How do we minimize total harms done by this pandemic? How do we save the most of us from the worst harms of the virus, and the worst harms of interdiction alike? These are serious questions, and they invite serious work to generate serious answers. That was always the proposition, and many efforts required to advance it –our own included– are now well underway.

But the United States may already have done too little, too late. The valid debate, inevitably disfigured in the meat grinder of pop-culture discourse, was like two surgeons conferring: do we need an incision from chest to navel (i.e., the surgical analogue of horizontal interdiction), or can we do this laparascopically (i.e., the surgical analogue to vertical interdiction)? If both agree that an operation is necessary -the one consideration already off the table is- doing nothing.

As the coronavirus toll from other countries became clear, the US did nothing. When we took action, it was impulsive rather than thoughtful and methodical: we closed the nation’s universities and sent legions of mostly healthy, young people to their far-flung family homes from sea to shining sea…without testing any of them for coronavirus. So far as I know, no one so much as took the occasional temperature. Such are the liabilities of…governance by twitter feed.

Even tests in a random sample before sending all university students home might have told us a lot; so, too, for the comparably large legion of young adults laid off from work in big cities and packed back to family homes. Did we, in this one fell swoop, inoculate the virus into tens of thousands of households- or more? Did we transfer exposure from those most likely to experience mild infection to parents, and grandparents, at much greater risk of severe infection, hospitalization, or even death?

I was worried on or about March 10 when I first put these ideas on the page; I was worried on March 20 when my column saw daylight in the Times; I was worried on March 22 when Tom Friedman’s column much amplified my own; and I am worried now – that the answers may well be: yes.

But now it is done. So- where are we?

We are in the crashing surf of contagion. The severely sick in need of hospital beds and ventilators, and at risk of dying- are there, thrashing, drowning. The health professionals fighting to save lives- are there, conducting every rescue they can. And the leadership in states awash in cases is there, scrambling for the surge supplies of protective equipment, beds, ventilators, and more a nation that was forewarned, but not forearmed, has made all too elusive. When swimmers are drowning in a massive riptide is a very bad time to start wondering if anyone thought to lay in a supply of personal flotation devices.

We may constructively think of a meticulous, methodical, thoughtful, national response to a crisis as a well-choreographed sequence of actions, much like a ballet, we can all agree: you can’t choreograph such a ballet in the crashing surf. You simply have to try not to drown. And for those not already being bowled over by the waves, the message is equally blunt: stay out of the water, and help those already there any way you can.

Those not drowning in this (i.e., the sick), or rescuing those drowning in it (i.e., health professionals and civic leaders sourcing supplies) can and should be focused on next steps. We need data, data, and more data, to know who is infected and who is not; who has symptoms and who does not; who is already immune and who is not; and how many from each group in the population are at risk of needing a hospital bed, of needing a ventilator, of dying.

We also need something like a ‘Total Harm Minimization Matrix’ that projects lives saved and lost under various interdiction approaches. I continue to believe- in the company of arguably the nation’s leading expert on pandemic response– that the most lives will be saved both immediately, and over time, if we differentiate among levels of risk for severe coronavirus infection in the United States, and move toward normalcy, and herd immunity, in a sequence of carefully data-informed phases. I have coined a name for the low-risk group that would lead the way: the SERLAWKI. That stands for: Selective Early Returners to Life As We Knew It.

There is more than one way for pandemic contagion to take lives, and more than one way to protect lives, too. All of the former are bad; all of the latter are good. But the delicate dance required to minimize total harms is impossible in a crashing surf. Having failed at early, rigorous interdiction of any orientation, that is where we find ourselves.

So, stay tuned for data-informed updates. If grown-ups are running the country during this crisis, we should have them soon at the national level. If otherwise, the effort will be more grassroots- but we will get there one way or another. When we do, we have the chance to save lives by many means.

But right now, with rescuers stretched beyond all tolerance- our contribution is to do all we can not to be among those needing a rescue. So, stay home, practice social distancing, wear a mask – while awaiting updates.

In other words, the nation is drowning in coronavirus; it’s our job to stay the hell out of the water.

-fin

This article was first published on LinkedIn.

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