The Continuing Need for a National Health Policy

Several weeks ago, I wrote a post about the need for a national health policy regarding the pandemic.  Obviously that hasn’t happened.

As the President and state governors have been talking about slowly opening up the economy again, stepping back from the restrictions on people’s movements, and in a few cases taken such action, I need to repeat my call for a national health policy.

When it comes to controlling a pandemic, the fact of states’ rights makes no sense.  Since all states are connected in many ways, but especially commerce and freedom of movement, it is critical that there be a national policy controlling the actions of people.

A national health policy does not mean “one size fits all.”  It means that there are national standards that will be applied.  Under those standards, some states may be allowed to open up before others, and those decisions would be made in concert with the governors, but it must all be coordinated under a federal standard.  

For those who say that under the constitution states have to be left to go their own way … nonsense!  The interstate commerce clause allows the government to regulate anything that impacts interstate commerce.  This has been read broadly and is the basis, for example, for federal civil rights laws.  Certainly it would provide a basis for a national mandated policy on efforts to control the coronavirus pandemic.  To not have a mandated national policy in situation would be madness.

People are the key to either containing the virus or spreading it.  There is thus only one effective way of controlling the virus.

When we come out of the lockdown phase, all experts agree that testing and contact tracing combined with quarantine is key to insure that the virus does not spike again.  Everyone who has symptoms should be tested, and if that is not available, should self-isolate on the assumption that they have the virus.  Under CDC guidelines, once they have been fever free for 3 days without medication, have had no symptoms, and it’s been more than 7 days since the onset of symptoms, they can assume they are virus free and can come out of quarantine.

Every contact someone has had (which could be as minimal as being in the same room or talking) with someone who is infected needs to be traced and told to self-isolate for 14 days, the incubation period, and be tested before being free to be out and about since one could be asymptomatic and still pass the virus to others.

In addition, because experts agree that the rapid spread has occurred in part because asymptomatic people have not been tested and quarantined, yet have passed the virus on to others, random testing should be done of a large percentage of the population to insure that asymptomatic cases are detected and quarantined until they test negative.

Ideally, all people who test positive and who live together with family or other communal situations, would be removed from their home and placed in an environment where they will be isolated so as to remove the threat of an entire family or living group becoming infected.  This is especially important if people are living in crowded environments with no private space available.  This will probably only be possible in limited situations for a variety reasons, and so following guidelines for separation in the home are critical.

Everyone arriving in the U.S. by plane or any means of transportation must at a minimum be temperature screened for the virus before being allowed to enter.  Interstate travel should be restricted to critical travel and all arriving passengers should be temperature screened.

What to do about people who travel by car interstate?  If everyone could be counted on to follow the rules, to keep to their quarantine, then one could assume that anyone traveling is free to move about.  However, that would be a naive assumption, plus testing is likely not to be as rigorous as it should be.  That means that people crossing state borders by car should be temperature screened.  This will felt as a burden on states and invasive to travelers, but the government must take every necessary action to contain the virus.

But all of this leaves the question … when and how do we end or ease the lockdown restrictions.  One suggested guideline has several criteria:  new cases falling consistently over 14 days; hospitals no longer maxed out; capacity to test all who should be tested; and the capacity to trace all those who should be.  Added to that list should be the ability to isolate outside the home those who are living in severely crowded living spaces.

Although ideally there should be no opening up until most everyone who needs to be has been tested or contact traced, and isolated if necessary, that is not feasible.  The ramped up testing and tracing will have to be done while people are beginning to move about.

Thus, when restrictions are loosened, everyone must continue to wear a mask when out in public and continue to practice social distancing to limit the number of new cases because the inescapable fact that some people will still be walking around with the virus.

Coronavirus Became a Pandemic Because of Man’s Hubris and Man's Lack of Individual Responsibility

As the New Year began, the first cases of coronavirus were reported in China.  Three months later, it is in the process of ravaging countries around the globe and creating economic havoc.  We are once again reminded of the power of natural forces and of man’s grandiosity in thinking that it doesn’t have to take them seriously.

Man could have prevented the pandemic.  Had a doctor in China been listened to by the local authorities, it could have been stopped and isolated probably in a small area of China.  Had the Trump administration been prepared following the advice of its own real-time pandemic war game in 2019, had the President and his advisers taken the threat of the virus seriously, we could have isolated the virus spread because it was all coming from outside the U.S.  No shelter-at-home, school closings, or other drastic measures would have been necessary.

But the Chinese local authorities and the Trump administration didn’t because we underestimate the power of nature and our own power, and we dislike inconvenient truths.  Both were guilty of hubris.  And so after 3 months, the world’s health and economy is in shambles, and will get worse before it gets better, despite all the money spent by governments to try and mitigate the damage.

More importantly, the lives of ordinary citizens have been terribly impacted, not only by the deaths, but by the financial devastation caused by the economic engine slowing almost to a halt.  Yes, they’ve also been inconvenienced by the lockdowns or “shelter-at-home” orders, but that inconvenience is small relative to the financial peril that many families are facing.

And because we are dealing with out-of-control nature, we really have no idea where it will end.  Perhaps after 2 months of stringent controls, local new cases will almost stop as in China and life can begin to return to normal.  But with the meager testing and tracking that even today is available in the U.S. compared to China and other countries, it is quite possible that the stringent controls will not be sufficient and new cases will continue to mount as infected but asymptomatic or mild-symptom people move about, albeit in a limited way.  A slight loosening of the restrictions without adequate testing and tracking could make matters even worse.

It is possible that the world will never be the same.  All we can do at this point is take one day at a time, stay calm, and do everything we can as individuals to not spread the virus.  

If everyone takes responsibility, this still could be contained despite the failed attempts of our government.  If you feel that you may possibly have the virus, get tested immediately, and if testing is not available, self-isolate and assume you are infected until you are proven to be well.  If you have come into contact with someone who is infected, self-isolate for 14 days.  

Practice good hygiene and wear a face mask when coming in contact with others in public spaces.  This last point applies to everyone, both infected and healthy … you wear a mask to not infect others, and you wear a mask to keep from getting infected.  If masks are not available, make your own from instructions available on the internet or use a scarf.

Although we’ve been told by the government and scientists for months that masks aren’t effective for the general population, the CDC and others are now urging that everyone should wear masks, as they do in Asian countries that have been more successful in containing the virus.  Just think of all the asymptomatic infected people walking around, unwittingly transferring the virus to others because they aren’t wearing a face mask.  Especially with limited testing availability.  That asymptomatic person could be you.

This will require a different leadership from the top than we have seen so far.  It is only individual people who can spread or stop the virus.  That point needs to be made very clearly.  And citizens must be called upon to play their part in this war.

The Light at the End of the Tunnel is an Illusion

As the percentage increase in new cases and deaths starts to decrease in some cities, I like many people have been heartened and have seen the numbers as an indication of the light at the end of the tunnel.  But today I realized why that is probably an illusion.

I live in an area of Massachusetts where people have been sheltering at home even before required.  Social distancing is the general rule.  But even after the CDC advisory about wearing masks when out in public, there has been little increase in people wearing masks.

I have asked staff at the local grocery and the hardware store why they aren’t wearing masks.  Sometimes they give me a shrug.  Or they just laugh it off.  When I tell them the facts about asymptomatic infected people spreading the virus and the percentage of false negative tests, they seem surprised.  But they don’t react with, “I’m going to wear some kind of mask.”  

They seem to feel they are impervious to the virus; it’s all about whether they need protection.  Wearing a mask is inconvenient or uncomfortable.  There seems to be no concern that they might possibly be asymptomatic and infect other people unwittingly.

Today at the hardware store I asked a manager and he said that he would only wear a mask if the CDC mandated he wear a mask.  When I said that the CDC advised that everyone should wear a mask when in public, he said it was voluntary.  That he didn’t want to wear a mask and instead of breathing the air, breathe in something from the material the mask was made of.  He also said that my assertion that wearing a mask prevented someone from unwittingly spreading the virus was false.  That he followed the 6’ rule and that was enough.  And finally that he’s gone through all the flu seasons and has not gotten sick.

This is an intelligent, thoughtful, careful man.  I don’t know what his politics are, but if someone like him doesn’t see why it is his duty, his responsibility, as a citizen to wear a mask after the CDC advice, then I fear that the light at the end of the tunnel is a mirage.

It is true that the percentage increase has gone down, but it needs to go down a lot more before we can even think about returning to normalcy.  If many people refuse to follow the advice from the CDC, as well as the advice on social distancing (and I’ve seen a good bit of that especially among younger people, and I don’t just mean spring break partying), then the numbers aren’t going to go down far enough.

What would change these attitudes?  I know that pleas from Dr. Fauci or Dr. Brix have had no impact.  There is only one person who perhaps might make a difference … the President.  If Trump finally really understood the danger we were in, understood his vital leadership role and wore a mask whenever he was in public, that would be a powerful symbol and without question many more people would wear a mask.

Republicans have been behind two major attitude changes that impact our ability to contain and survive the virus.  The first is the disrespect for government that Republicans have fostered for the last several decades beginning with Reagan’s “Government is not the solution to our problem, government is the problem.”  The second is the disrespect that Trump has sown towards science and facts.  And it is only Trump and his fellow Republicans that can turn this attitude around.

Even Now Trump Doesn’t Get The Pandemic

President Trump still doesn’t get it.  To contain the pandemic we must be ahead of the epidemic, not behind it.

Unfortunately, from the start, Trump has been behind.  First he belittled the threat and did nothing.  During the month before he restricted travel, 380,000 Chinese entered the country with no screening, many unwittingly bringing the virus with them.

Second, we didn’t have enough tests and so we turned to lockdowns, at a huge cost to the economy and the welfare of our citizens.  

Third, we still don’t have enough tests or testing capacity or tracing capacity.  We really don’t know what the scope of infection is in the U.S.  There are critical states, like California, which have done much less testing per capita, yet looking at the volume of passengers that flew into LAX during January, it is hard to believe that the numbers aren’t much worse than they are reported.

Fourth, he continues to refuse to order a nation-wide shelter-in-place policy.  Doesn’t he understand that people travel, and when people travel so does the virus?  Remember that 25% of infected people don’t know it because they have no symptoms.  And false negative test results are a troubling 25%.

Fifth, it’s critical that everyone follow the new CDC advisory and wear a mask when out in public.  But our President says he’s not going to do it; it’s completely voluntary.  He neither has any concept of leadership nor an understanding of the danger we face.

Finally, when the numbers stabilize and talk turns to returning back to normalcy, all experts agree that can only happen if we have the testing and tracing ability to examine all new cases of virus infection.  Otherwise we risk having another explosion of cases and a return to lockdowns.  What is the plan to achieve that capacity?  There is none.  Again, Trump just doesn’t get it.

Trump's Responsibility for U.S. Exposure to the Pandemic

Yes, Trump is responsible.  How has Trump failed each and every one of us, just as regards the coronavirus pandemic?  Let me count the ways.

1. In 2018, the Trump administration dismantled a group with the National Security Council charged with preparing for when, not if, another pandemic would hit the nation.  When it came, we were unprepared.
2. Last September, the Trump administration eliminated the position of a CDC expert embedded in the Chinese disease control agency.  She would have known almost immediately when the virus was first reported internally to the Chinese agency and allowed the U.S. and all governments to move much faster.  Instead, at least a month was lost, as well as us being dependent on Chinese information rather than having our own person on the ground.  (See Reuters report, March 22, 2020)  When it came, we were unprepared.
3. Last September, the White House Council of Economic Advisors released a report that stated that the economic damage of a pandemic influenza would be $413 billion to $3.79 trillion, with up to 500,000 deaths and between 670,000 and 4.3 million requiring hospitalization.  When it came, we were unprepared.
4. Last October, the U.S. Dept. of Health and Human Services reported on a pandemic simulation it conducted in real time between January and August 2019 on a fictional respiratory virus that began in China and quickly spread around the world by air travelers.  The results were catastrophic:  11 million Americans infected, 586,000 dead.  The draft report on “Crimson Orange,” the code-name for the exercise, showed how underfunded, underprepared, and uncoordinated the federal government was for this eventuality.  A final report appears not to have been issued and the Trump administration took no action based on the report.  When it came we were unprepared.
5. Once China reported in early January that there was a new coronavirus that had infected hundreds of people (the first case actually appeared in mid-November but the virus wasn’t identified until late December), given the fast and vast potential for the virus’ spreading, Trump should have immediately started temperature screening all flights arriving from China, and all passengers arriving from other countries who had been in China during the previous month.  That would have prevented, or at least greatly limited, the spread of the virus to the United States.  
6. Instead, travel restrictions from China were imposed on January 31, prohibiting all who had been in China within the past 2 weeks from entering, except for U.S citizens. Unfortunately, in the previous month, roughly 300,000 people entered the U.S. from China, so the virus was already among us.  Americans could inexplicably still go back and forth to China with no restrictions.
7. Despite his own administration’s pandemic report (which as stated above was never finalized), Trump continued to minimize the risk to the U.S., citing the small number of cases.
8. The U.S. was unprepared for a necessary massive testing and contact tracing effort.  For some reason, no one with any clout in the administration seemed to realize early on the critical nature of massive testing and follow-up tracing and quarantine to containing the virus.   But his is Infection Disease 101; basic.  Across-the-board social restrictions would slow but not stop the virus.  The emphasis seems to be on insuring we have enough medical supplies, ventilators, etc.  That is certainly important.  But testing and tracing (which requires a large labor force) is critical.  Yet the testing gap is hardly mentioned.  Though it is on Dr. Fauci’s mind.
9. The administration, and admittedly most scientists, told the American public that if they were healthy they would not benefit from wearing surgical/construction face masks and should not wear medical N95 masks because they were limited in number and needed to be reserved for health-care workers and those who were infected.  Of course there was a run on masks of any type regardless.  But still, you see almost no one wearing any type of mask.  

           Recently, The New York Times reported that some U.S. scientists are saying that 

           even regular masks can be helpful because some protection is better than none.  A 

           lead Chinese scientist has said that a major problem is that people in the U.S and 

           other countries are not wearing masks.  And the latest, the CDC is reviewing 

           whether to recommend broad use of masks because of asymptomatics' spreading 

           the virus.

           Masks serve 2 functions.  If you are infected or possibly infected, the N95 mask 

           traps droplets in the mask so others won’t be infected; the regular masks at least 

           interfere with the emission of droplets, some protection again being better than 

           none.  If you are healthy, even the simple masks provide at least some protection 

           from droplets and also make it less likely you will touch your mouth and nose while 

           you are out and your hands have not been washed.

Looking back on this chain of events, there is no question that Donald Trump, and his administration, are responsible for the rampant spread of coronavirus in the U.S.  Both by acts of omission and commission, Trump has left the country totally exposed to this pandemic and we the people will as a result suffer in innumerable ways.