Parents teach their children not to run in front of speeding cars. To survive a crisis, you learn from those who handle it well.
As of today Taiwan has had six deaths from coronavirus, South Korea 234. Both learned from previous lethal coronaviruses, SARS and MERS. Both have robust public health structures where epidemic response is coordinated and run by national health crisis authorities made up of epidemiologists, medical doctors, and scientists. Daily reports are given to the nation.
How did Taiwan keep their epidemic so controlled? Here are some factors:
- National Health Insurance covers everybody and has a data base to track everyone. Contrast – the US has no national data base. Our vaunted electronic health records not only take up perhaps half of clinician time but only represent a heavily siloed patchwork of uncoordinated data stores. The large majority can’t “talk” to each other, while getting information from them is a major “profit center.” The data is not owned by the government, patients, even the clinicians who generate it, but by the companies.
- Heavy and consistent testing of people coming into the country – about five percent of Taiwan lives in the People’s Republic of China, the the initial point outbreak of Sars Cov 2 and SARS.
- The government requisitioned companies and the military to make masks by the millions each day. They set the price, and rationed them.
- Anyone testing positive was quarantined and tracked by cell phone. High fines were levied for those leaving their homes for the two week isolation period.
- Companies profiteering on the crisis were fined.
- Media figures creating“false news” about the nature and control of the virus faced new criminal penalties.
- All these official actions were taken to control the virus by February 21st. Since epidemics grow exponentially, you panic early.
- Attempts were made to trace and track every case. Cases and contacts were isolated for fourteen days, as quarantines have done for centuries.
- Travel data, health records and cell phone data were integrated. This was done perhaps more actively in South Korea, where a positive case causes messages to be sent within minutes about what stores and places were visited by anyone testing positive to every cell phone in the area.
Pointedly, information was sought and brought to immediate attention at national headquarters with the entire population regularly and rigorously informed.
The U.S. classified its deliberations on the pandemic. On April 15th, Vice President Michael Pence, officially in charge of America’s response, said “As we stand here today, 24 percent of the counties of this country have no reported coronavirus cases. In fact, half of the states in America have less than 2,500 cases per state.”
How do you know? Have all the people in those states and counties been tested? Have there been random epidemiologic population surveys? Was the promise that “anyone who wants a test” set forth by the president weeks before fulfilled?
By contrast, the relatively apolitical vice president of Taiwan is an epidemiologist who won acclaim for fighting SARS in 2003. He might have interesting comments on our vice-president’s handling of the AIDS epidemic in Scott County while governor of Indiana.
A little context: in early February, flu researchers like Rachel Chu of the University of Washington were noting lots of “flu” cases that were not testing positive for flu. They were pretty sure these folks had coronavirus. They petitioned the CDC to find out.
The CDC response was no way. You can’t do test. It’s illegal. Don’t think of doing it (https://www.nytimes.com/2020/03/10/us/coronavirus-testing-delays.html.)
When three weeks later Rachel Chu broke the law, she recognized cases of Sars Cov -2 had been developing in Seattle since at least mid-January.
The FDA told her to cease and desist. The CDC did not want to know. This is akin to generals soon to start a battle refusing to listen to their intelligence officers tell them the order of battle of their enemies. Our plan of attack is so perfect, so foolproof, we don’t need to know anything else about our foes.
One epidemiologist credits Chu’s breaking the law with changing the results in Seattle, where otherwise the epidemic “would have been ten times worse” https://mynorthwest.com/1758762/coronavirus-washington-seattle-flu-study/?)
Such a policy suppressing testing had to come from the top. The highest levels did not want to know how many people had the virus. And if we don’t count, nobody else knows, right?
Sadly you can fool the people, but you can’t fool Mother Nature.
If you want to loosen lockdowns, you need to something about your enemy and what it will do.
Germany is preparing for its loosening of lockdowns by setting up studies to see what occurs. Do case numbers go up when we let people freely into parks? Nobody as yet knows enough (you hope open air ventilation halts respiratory spread,) so there will be studies to try and find out. The Swiss will soon allow hairdressers and massage parlors to open. Will they track to see if cases go up?
Of course they will. So will Germany, with its nationally coordinated but independent 400 public health and testing authorities. As you loosen restrictions, you actively test the population, trace and track cases, then see what else you might open up.
Hong Kong is preparing for loosening restrictions by consulting with epidemiologists who will actively look at Rt, the reproductive rate of the virus. Germany is alreading calculating its national numbers, which can change daily. A number below 1 means one person infected will infect less than one in turn, leading eventually to the epidemic dying out. The original R when Sars Cov 2 hit was estimated at 2.4 to 3, provoking exponential growth.
Contrast this with Florida, where Governor de Santis called for a lockdown on April 2nd, long after most of the country. Interestingly he exempted places of worship. The large majority of cases in South Korea were traced to the Shincheonji Church of Jesus; major point outbreaks in much of the rest of the world like Qom in Iran and New Rochelle originated with worshippers at packed religious services. Most countries reluctantly banned such public worship. But, as the governor explained, “I don’t think the government has the authority to close a church.”
We can consider the impact of lockdowns by graphs prepared by epidemiologists at Imperial College, London and London School of Hygiene and Tropical Medicine. In their models the expectations of 4000 deaths in Florida would have been cut by at least 80% (https://www.nytimes.com/2020/04/14/opinion/covid-social-distancing.html) if the lockdown had occurred two weeks earlier.
That’s just a model. Let’s assume an earlier lockdown would have saved not 3,200 but just 2,000 lives. At present prices of $10 million per death, used in insurance and other studies, that comes out to 20 billion dollars, about the price of a major hurricane.
But you can’t prevent hurricanes. Hurricanes don’t leave people frightened to enjoy Florida’s tourist spots like Disneyworld, or leave them too scared to enter a restaurant. Or go outside.
Hard headed realists might argue that the lives of people in care homes are worth far less than that a young entrepreneur. Such ideas underpinned Britain’s original response to the pandemic, whose program director, Prime Minister Boris Johnson, reversed course before becoming severely ill with the virus, in time to watch his nation experience a galloping epidemic.
Information saves lives, ignorance kills. At present the U.S. does not have the testing, tracing and tracking infrastructure to know what loosening of lockdown will do to the nation’s health and economy.
But we could. Former CDC director Dr. Tom Frieden estimates an epidemiologically directed force of 300,000 could give the U.S. the information it needs. With tens of millions out of work, they could easily be recruited, though training would take time. Germany uses furloughed teachers and state workers.
We could also nationally coordinate testing, an epic mess with 30 different manufacturers generally unable to source the required materials like reagents for their proprietary products.
The kind of work quickly performed by Taiwan and Korea. Nations who actively track their population’s health can also provide us guidance on how and when we can open up shops, parks, and schools. Our epidemiologists can cooperate with theirs to determine real time Rts, letting us know what policies work. Everybody wants to withdraw restrictions and return to more normal life.
Yet some national leaders will continue to act without necessary evidence or information, playing Russian roulette with their national health. They may respond to the outbreak like Brazil’s President Bolsonaro: “we’re going to face the virus like a man, dammit, not like a little boy.”
President Bolsonaro is not the only exception.