COVID-19: What has brought us here, where do we go next? (July 2020)

Mid-July 2020 and we, in the United States, find ourselves in a difficult place vis-a-vis the virus. It is a challenging moment and past time to think about what brought us here and what we need to do right now to get out of the worst of it and move forward.


I offer the following as a way to get us to the place where we can use the tools of disease surveillance to manage the virus until longer-term solutions—therapeutics and vaccines—can be put into practice. Implementation of traditional surveillance tools will enable schools and universities to move to in-person instruction, allow many businesses to offer services, and give people confidence in being in these spaces.


All of these things—schools and universities in-person and businesses offering services—will NOT be done according to the standards of pre-COVID life.


They will not.


However, with appropriate disease surveillance, we can start to achieve lifestyles that are, psychologically and socially, healthier than the current situation.


But, to arrive at a place where the traditional tools of disease surveillance for infectious diseases—testing, tracing, isolating, and quarantining—can work is going to require several things and, most importantly 1) clarity about how we have gotten here and what we need to avoid going forward, and 2) the key behaviors we all need to adopt now AND going forward until therapeutics and/or vaccines are broadly available.


The second point is VERY important: our behaviors need to transcend any understanding that there are ones that are appropriate for when we are “open” and others that are appropriate when we are “closed”. Indeed, it is clear to me that the concepts of “open” or “closed” (or shutdown) have become a hindrance to having a rational conversation about the behaviors necessary to get us through the crisis until treatments or a vaccine are widely available.


We need a clear set of behaviors that hold no matter the level of openness; that hold whether schools are in-person or not; and that hold whether businesses are providing goods and services or not. Why? Because these are the behaviors we need to “live with COVID-19” as the infectious entity it is.


So, what has brought us here? I would suggest six things, some of which we do not control and most of which we do.


  1. SARS CoV-2 (the virus that causes COVID-19) is a novel coronavirus. We know a lot about other respiratory viruses, and coronaviruses have been around for a long time. But THIS virus is new. It is more infectious and more deadly than other coronaviruses and we know little about its long-term impacts on those who are infected but survive. We are still learning about how it is transmitted (though our knowledge has grown quickly). Many of the other points below flow from this virus’ “novelness” and our lack of experience in dealing with such an efficiently spread disease like it.


  1. There is a great deal of misunderstanding about how science works. This is something we could control if we wanted to. Science does not advance with statements of absolute certainty—especially when it comes to novel infectious agents. Science advances with evidence built, hypotheses proffered, and corrections made over time. Many of us are watching the “art of science” practiced in public for the first time and while science speaks in “evidence for” and “probable outcomes”, newspapers (and politicians—see below) speak in headlines and an appearance of certainty and confidence that scientists find horrifying.


  1. We lack humility. I say this in two ways: we lack humility about the need to learn more before we speak in any certain terms about this virus; and we lack humility about how we use information to score points in arguments. We need to step back and acknowledge that there is much we do not know and share our learnings in careful terms, ready always to self-correct, acknowledge errors, and move on to make better decisions based on the weight of evidence.


  1. We have politicized EVERY element of this virus and our response. From its origin, to treatments, to testing, to preventive measures such as the wearing of masks, it is hard to talk about any part of this that has not been mobilized to denigrate rivals or advance narrow political ends. This demonstrates both a lack of humility AND a willful misunderstanding of science (or it is pure cynicism). From the president, who suggests scientists are lying to us, to local officials who call for “reopening” so we don’t “fall behind” the next county over, our leaders have too often used the virus to their ends, not ours. This has given the impression to normal folks that EVERY recommended behavior is contested and that there is no evidence, no truth, no clear path.


  1. We have created unnecessary binary thinking. This is the main tool of the politicization noted above. We have created false dichotomies: health versus economy, or death of a few versus mild illness for everyone else, and the list goes on. These binaries have hijacked our discourse, created confusion, and have kept us from advancing a more nuanced understandings of how we might move forward.


  1. We have been extremely impatient. Did I mention that this is a NOVEL coronavirus? Did we forget that it is has been infectious to humans for under 8 months? Despite this, we want answers, we want resumption of a normal life, we want normalcy to return. NOW! Well, none of that is going to happen quickly. None of it. And so, we must prepare for a long struggle and rediscover the value of patience and waiting (traits that many people in the world consider virtues).


This is how we got here and the negative synergies in the foregoing list describe why we feel helpless and angry, and unable to find a way through. But there is a way. It is not an easy one, but it is one that takes all of the foregoing and turns it around in three clear steps.  

It is what I think of as the “Steps to Living with COVID-19”


First, we need to follow some very basic guidelines that have already been established AND expect them to be updated. Remember how science advances: it learns, it updates, it corrects. If every changed or updated recommendation is met with derision and hostility, if every correction is viewed as evidence of malintent, we cannot move forward. We need to see changes to recommendations as evidence that we are learning to overcome this disease and embrace them.


Second, and this is one of those recommendations, we need to wear masks indoors at all times when others are present, except at home. Period.


We also need to wear masks outside when in crowds or in any other context in which six feet cannot be maintained between us and others.


Third, we need to avoid what the Japanese have termed the three C’s. We need to avoid CLOSED spaces with poor ventilation. And since we typically do not know about the ventilation in closed spaces, we should be careful in all closed (tight, low ceiling, narrow, confined, etc.) spaces if possible.


We need to avoid CROWDED places with many people nearby. This means indoors and outdoors but especially indoors and especially for periods longer than an hour. Outdoor crowded spaces? See masks above. Indoor crowded spaces? Avoid them with or without a mask.


We need to avoid CLOSE CONTACT—that is, close-range encounters with people. We must use masks but even with them, we should avoid prolonged conversations close to people (<6 feet).


We should specifically avoid situations where all three of the “Cs” are present because those are the situations of superspread events.


Many other details could be hashed out in any of these but if you take them as a hierarchy—masks first and then the three C’s—they will guide much of your behavior.


If we do these things, we will drive transmission down to a point that we will be able to catch the few cases that occur DESPITE these behaviors. That’s right, none of these individually or taken together reduce risk to zero. We are facing a highly efficient virus that can spread despite our best efforts. 


But, if we do these things, we can manage the cases that slip through, with lowered mortality, with schools and universities having in-person instruction, and with local businesses offering goods and services to clients. All of these will be modified but our lives will begin to feel somewhat normal and we can begin to regain the full social, cultural, and economic health we desire.


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