COVID-19 is not an even-handed scourge.
The risk of severe coronavirus infection, and death, are highly concentrated among those over age 80, to a lesser extent among those over 70, and in particular where baseline health is already poor. To maximize the efficiency of our harm reduction efforts- containment, prevention- they should be targeted accordingly.
The coronavirus pandemic demands of us all a bracing dose of humility; no one can know the ideal set of actions to minimize the net harm. We will only know that in retrospect, after a careful analysis of what worked well and what did not- and perhaps we won’t know the optimal response even then. But either way, “then” will be too late to do us any good now, so this is also a time for accepting the imperfection of our best guesses, and doing all the good we can manage.
Among the things we do know are reasons for some, even considerable, comfort and reassurance amidst this historic crisis, given you don’t have a serious chronic illness, significant immunocompromise, lung damage due to smoking, and/or are not yet over age 70. Reflections on suitable action for those in these higher risk groups momentarily.
For those who are not, the risk of severe infection appears to be very low. The best data we have for a full population come from South Korea, which has tested faster and far more comprehensively than any other country, by a wide margin. Of the approximately 8236 cases recorded there to date, 99% are registered as “mild.”
The risk of death is lower still, at roughly 0.8%. This means the overall likelihood of recovery is 99.2%, but that is misleading. The death rate is highly concentrated- almost 98% concentrated- among those over age 70, and further concentrated among those over age 80. There have been no deaths at all in anyone under age 30, and almost none in those 60 and younger.
This is not intended to discount the significance of mortality from coronavirus at any age. But the simple fact of epidemiology is that we are more likely to die from many causes, and in general, as we grow old. So, in the oldest group, death from coronavirus is likely to be instead of death by another cause at a not too distant time.
So much for the reassuring news. What about the rate of infection in the general population? We are hearing that Italy’s health system is becoming overwhelmed even as I write this. That is in part due to panic and misdirected effort, but also partly due to the rapid spread of this virus. Italy is reporting over 2158 deaths from COVID-19, but only 27980 cases. With a death rate of roughly 7.3%, the reality is almost certainly that Italy has 100,000 or more cases already. Much the same is true in countries around the world.
That level of dissemination means that any opportunity to contain the virus has come and gone. We are all seeing the massive disruption associated with culture-wide, and in my view, haphazard containment efforts. Here are my thoughts on what makes the most sense; I house my suggestions under an acronym, DCISEV (pronounced as “decisive”), standing for “Directing Crisis Intervention Services to the Especially Vulnerable.”
Hospitals are long accustomed to special procedures for handling highly infectious patients, or those highly vulnerable to infection. These should be adapted for use around all facilities housing those at elevated risk for severe coronavirus infection.
Perhaps we can help shelter the frail elderly from exposure to coronavirus with enhancements to services like Meals-on-Wheels, distancing them from others who might transmit the virus. To the extent possible, with an overlay of careful infectious disease control, this should be done. This would be a potentially high-yield use of social service resources, visiting nurse services, and as needed- the National Guard.
If we can’t provision the frail elderly effectively in their widely scattered homes, there is another potential option.
The coronavirus upheaval means that hotel rooms are going unused as work shuts down, trips are canceled, and more people stay home. We might temporarily reallocate hotels as housing facilities for those most vulnerable to severe coronavirus infection before they are exposed (this means universal testing at entry). Those with chronic illness and the elderly should be offered, in communities throughout the nation, the opportunity to check into hotels at low or no cost to “ride out the storm.”
We can employ strict infection control protocols here, too; test comprehensively- and consolidate service delivery. We can deploy health professionals to help supplement the hospitality staff, and while this increases demand on the health care system- it does so far less, and in a far more predictable manner, than the current mayhem overwhelming Italy, and threatening us here.
And, as a bonus, the hotel industry has something to do, rather than going idle and being yet another drag on the economy.
Related to both of the above measures, we should concentrate available testing where it will do the most good, until we have the kits needed to test population-wide. We must very carefully control the potential introduction of an already infected individual into a vulnerable population- and that means systematic testing wherever vulnerable populations are congregated, notably hospitals and long-term care facilities, or any facility we convert temporarily to shelter the especially vulnerable.
There is much clamor for “flattening the curve,” namely slowing the rate of spread so the system is not overwhelmed all at once. Advancing this goal with the temporary cancellation of large social gatherings makes obvious sense.
Extending the practice to a veritable shutdown of normal societal function is far more questionable. This infection is already wide spread, and so containment in the general population may no longer be possible. Even if it is, the flatter curve extends out for a much longer time. That means the same number of people eventually get infected, but the social upheaval and net cost- in lost productivity, supply chain disruptions, and other adverse health effects- is higher. There is a crucial trade-off here between the acute burden associated directly with COVID-19, and the indirect effects of a protracted, societal shutdown. Those effects extend beyond economic damage to lives lost, too, as a result of service disruptions, severe stress, and other “unintended consequences.”
We might achieve the same overall benefits by sheltering those most vulnerable to severe infection, and concentrating our efforts there- while allowing society at large to keep functioning rather than shut down. This is a strategy that blends flattening the curve to whatever extent practical by the most impactful but least disruptive approaches, with “trimming” the curve- by preventing the most severe infections preferentially. Mild cases of coronavirus do not require hospital care, so to avoid overtaxing the system, it’s the severe cases we must strive to prevent. We know where that vulnerability is concentrated; our containment efforts should be concentrated there, as well.
To keep those with mild infection away from hospitals and vulnerable populations, we should be identifying them elsewhere. Testing for coronavirus should be done as far from hospitals and clinics as possible. We could deploy mobile units to carry out testing at community sites, assuming we have the test kits available in the first place.
For the treatment of those with mild infection, and because the ultimate toll of illness is uncertain, we should prepare surge hospital capacity. The military and FEMA have the capacity to erect temporary hospitals, as do some NGOs. These preparations should be in place before we need them, of course. If we shelter those most prone to severe infection, and contain those effects we are not likely to need much surge capacity- but better safe than sorry. If we fail to contain spread in the most vulnerable populations, we will certainly need this resource.
With the above policies, radical though it may sound, we could actually resume business as usual in many respects, allowing young, robust people to go about their routines. Most of us are going to get this virus anyway- we may as well be productive and keep goods and services flowing while “waiting.” This is good for the people who need those goods and services, and good for the economy at large. It will also save some lives.
All of the young people who get infected will likely develop partial or full immunity to this virus; that leads to the fifth and final recommendation:
When we have a vaccine, those who did not get infected- notably, the elderly we effectively shielded from exposure- should be immunized. This will require not just the development of an effective vaccine, but an end to the misguided anti-vaccine sentiment that takes hold whenever a disease becomes familiar enough to induce our “contempt.” The flu has been killing at a massive global scale year-in, year-out, yet many go unvaccinated based on Internet conspiracy theories. Here, the coronavirus is a reality check: lethal pathogens are the public enemy, not the vaccines that prevent them. To date in the United States, there have been 77 deaths from coronavirus, while seasonal flu has caused as many as 50,000.
As for the practicality of the above, much of it could be implemented at a state level. So, for any favorably disposed and with access to a Governor's ear- these reflections are at your disposal.
Based on what we know from the best data around the world, I believe we have a mandate for DCISEV action against COVID-19. But there is a lot we don’t know, so we should stay nimble, and prepared to shift our policies and practices if and as our experience with the pandemic demands. And, of course, we should apply all we learn from this pandemic to mitigate- and ideally prevent- the next.
Dr. David L. Katz is a board-certified specialist in Preventive Medicine/Public Health
David L. Katz, MD, MPH, FACPM, FACP, FACLM, is the Founding Director (1998) of Yale University’s Yale-Griffin Prevention Research Center, and former President of the American College of Lifestyle Medicine. He has published roughly 200 scientific articles and textbook chapters, and 15 books to date, including multiple editions of leading textbooks in both preventive medicine, and nutrition. He has made important contributions in the areas of lifestyle interventions for health promotion; nutrient profiling; behavior modification; holistic care; and evidence-based medicine. David earned his BA degree from Dartmouth College (1984); his MD from the Albert Einstein College of Medicine (1988); and his MPH from the Yale University School of Public Health (1993). He completed sequential residency training in Internal Medicine, and Preventive Medicine/Public Health. He is a two-time diplomate of the American Board of Internal Medicine, and a board-certified specialist in Preventive Medicine/Public Health. He has received two Honorary Doctorates.