COVID-19: Public Health Will Save Us
By: Joe Pamintuan
Tags: Vaccines, Coronavirus, Covid 19, Virus, Public Health

In mid-November, the White House Task Force on COVID-19 warned of the “accelerating community spread” of coronavirus, with hospitalizations at an all-time high (73,000) and over a quarter million deaths. Infection rates were rising in multiple states, even in rural areas in the Midwest and hinterland in places like North and South Dakota and Wisconsin. Seeking to stem the spread, the Task Force called for heightened vigilance and the expansion of screening regimes. Yet one month later, the situation continues to deteriorate: 110,000 Americans are now hospitalized with COVID, and over 300,000 have died from the disease. And, with 2,400 Americans dying from COVID-19 every day, there seems to be no end in sight. Earlier this month, we hit another grim milestone: 15,000 COVID deaths in one week.

Of course, many predicted that infection rates would rise come winter: cooler temperatures drive people indoors, reducing ventilation, and there is evidence that cold, dry air itself enhances viral transmission. What is alarming is that the nation hit record infection rates and hospitalizations well over a month before winter. And cooler weather also brings flu season, as if one deadly virus were not enough: Each year, flu claims between 15,000 and 38,000 lives according to the Centers for Disease Control; co-infection with flu and coronaviruses could therefore be a death sentence. To make matters worse, we are on the cusp of the Christmas and New Year’s holidays, the busiest travel season of the year.

In short, we are faced with a confluence of factors that seem set to aggravate an already precarious situation — cold weather, flu season, and the busy holidays — whose impacts have yet to be fully manifest. And we still have the entire winter ahead of us. So, the recent announcements by Pfizer and other vaccine makers like Moderna, whose vaccine won emergency approval this month, could not have come at a better time. Vaccinations for the elderly and immunocompromised have recently begun, which is especially welcome news for more vulnerable populations. But many experts have expressed their reservations: “These achievements will come too late,” wrote Thomas Bossert, former Chief Homeland Security Adviser under President Trump, in a Washington Post piece written with Richard Danzig, former Secretary of the Navy, and James Lawler, an infectious disease physician and co-director of the Global Center for Health Security at the University of Nebraska Medical Center.

“No vaccine will save us,” warns Dr. William Haseltine, a retired virologist at the Harvard School of Public Health, likening the coming vaccines to sheriffs in Hollywood westerns who arrive too late. The pandemic, therefore, has “no end in sight,” even if vaccines are proven effective, which won’t really be known for months after roll-out, he adds. Moreover, distribution and availability for any of the vaccines will vary. “A U.S. official says a vaccine could reach the general population by May or June,” the New York Times reported on December 6th, “but Biden has sounded a considerably more skeptical note about its distribution.” Indeed, the President-elect has repeatedly implored Americans to wear masks for the next few months. Even infectious disease expert Dr. Anthony Fauci, who has expressed enthusiasm about progress on multiple vaccines, stressed the need to “double-down” on measures like wearing masks and social distancing.

Bossert, Danzig and Lawler go further, calling for blanket restrictions on social gatherings and the closing down of restaurants, bars and clubs. Indeed, while the United Kingdom has already begun vaccinating the elderly, nursing home workers and other high-risk populations, it recently imposed “Tier 4” COVID-19 restrictions — full lockdown. These precautions seem even more appropriate in light of new findings from South Korea, where contact tracers have documented the transmission of coronavirus between restaurant patrons sitting over 20 feet apart within five minutes. This suggests that the 6-feet social distancing rule is woefully inadequate, adding credence to renewed calls for lockdowns in hard-hit regions.

Thankfully, these voices of caution are beginning to attract attention from the top. Alarmed at the deteriorating situation, the White House Task Force on COVID-19 recently called for enhanced public health measures, including “proactive and increased testing and surveillance,” especially to target asymptomatic cases, along with “mask wearing, physical distancing, hand hygiene, and immediate isolation, contact tracing, and quarantine,” according to CNN.com, reporting on a Task Force guidance issued to states. The key is that this must be a coordinated and unrelenting effort, involving the full cooperation of local and federal authorities, if the experience of South Korea is any indication. With its well-conceived national public health response, it managed to essentially contain the virus within twenty days without lockdowns.

While South Korean officials deployed information technology to track progress and broadcast alerts, much of their success can be attributed to rather conventional measures like surveillance testing, albeit on an industrial scale, and dramatic improvements in contact tracing: BBC reporters who shadowed South Korean officials found that they were able to trace all the contacts of an infected case in less than an hour, down from several days at the start of the outbreak. This improvement was instrumental in the control of a virus for which asymptomatic transmission plays a critical role.

In a word, we must maintain a razor-sharp focus on public health even as vaccines are rolled out. Some may argue that what worked for a smaller, albeit densely populated, country like South Korea might not apply to a geographically larger one like the U.S. Yet the experience of China, which is about equal in size to America but has nearly five times the population, suggests that public health measures, rigorously carried out locally but coordinated at the national level, may prove the decisive factor in containment even for a large country filled with sprawling, densely populated cities — like the United States. Indeed, that was the conclusion of a leading international epidemiologist and his team who traveled to Wuhan during the height of the outbreak last winter.

Many outside observers attribute China’s successful containment to draconian measures like strict city-wide lockdowns. But Dr. Bruce Aylward, a physician and epidemiologist who led a fact-finding WHO mission to Wuhan in February to observe the coronavirus response, told NPR in March that this “would be taking the wrong lesson.” Lockdowns, he stressed, “were only imposed in several cities,” most famously Wuhan, the epicenter of the outbreak.

What, then, was the critical factor? “They really went back to the fundamentals of public health,” he explained, citing the time-tested tools of “isolation, contact tracing and testing.” Dr. Aylward concludes: “They actually changed the course of a respiratory-borne outbreak without a vaccine, which was extraordinary.” The WHO’s report found that “China’s uncompromising and rigorous use of non-pharmaceutical measures to contain transmission of the COVID-19 virus in multiple settings provides vital lessons for the global response,” emphasizing the country’s “unique and unprecedented public health response” that “reversed the escalating cases.”

When the report was released in March, many presumed that it was premature or inaccurate, and some even accused WHO officials of incompetence. But these health officials have been vindicated by the fact that the virus has been kept at bay ever since. Tellingly, China has accrued so few cases since the spring that its scientists were forced to conduct vaccine trials abroad; with little chance of community transmission in China, it would be difficult to gauge the effectiveness of vaccines. In fact, during the country’s Golden Week holiday in October, the travel website Ctrip logged 600 million trips, demonstrating the extent of containment and the public’s faith in the ability of the government to keep everyone safe. This trust is well-earned: when three people subsequently turned up COVID-positive in Qingdao, authorities tested every single person in the city — nearly 11 million people. A report in The New England Journal of Medicine cited the city’s “aggressive contact tracing and quarantine of close contracts,” noting that only nine more cases were identified.

Clearly, public health is paramount, and if it could make the decisive difference early on in the pandemic, when hundreds were dying every day in Wuhan from a mysterious respiratory illness, then it can and should play an even greater role now, given that we now know so much more about the virus and are armed with faster, more accurate tests. More important, we have proof that containment can be achieved over a vast area and large population and sustained for months. The question is, how do we deploy the tools of public health to achieve this?

Unfortunately, there has been scant attention paid to China’s containment program. Yet many in the know have called for taking a closer look: Robert Hormats, a former Undersecretary of State and economic advisor to three national security advisors, urges closer cooperation with China on COVID-19: “Public health officials here can learn techniques on how to better control the spread of the disease,” he suggests in a November 15th piece for TheHill.com. Acknowledging the two countries’ penchant for political confrontation, he observes that “American and Chinese scientists have a long history of working together in the field of medicine,” adding that “the U.S. still has a big stake in cooperation between American and Chinese researchers and scientists on development and production of therapeutic treatments and a vaccine for COVID-19.”

I don’t mention China because I want to praise an authoritarian, communist regime; I mention China because, when it comes to COVID-19 containment, it matters little that it’s an authoritarian, communist regime. Indeed, the successful control of coronavirus by countries with disparate political systems, like South Korea, New Zealand, and Taiwan (democratic) and China and Vietnam (communist), is proof that containing the virus doesn’t come down to political systems or relative freedoms but to sound public health measures coordinated at the national level. This should be reassuring news as we grapple with record infection rates and hospitalizations, for it means that there is so much we can do right now to curb soaring infection and hospitalization rates. This might include dramatically expanding testing and surveillance programs, as the White House Task Force recommended last month, and steadily reducing contact tracing times, as was demonstrated in South Korea.

But even as vaccines are rolled out, we must not let down our guard. Yes, multiple vaccines have been shown to be effective in trials but, as Dr. Haseltine noted, their real impact won’t be known for some time after they have been distributed widely. Until then, he warns, we face a “dark winter.” Therefore, we must do all we can now to steadily and relentlessly improve our public health response and maintain this focus as vaccines are rolled out. Only then will we be able to slash surging case and hospitalization rates — and save lives.