COVID-19: What We Know, and What We Don’t

ERIC SCHNEIDER: What a pandemic does in general is it magnifies whatever disparities and whatever problems already existed in a health care system.

SHANOOR SEERVAI: Hi, everyone. Welcome to The Dose. This week, we’re doing another special about the COVID-19 pandemic. We’re doing this episode because so many of us are desperately searching for information on what to do to keep ourselves and our loved ones safe. But things are changing so rapidly and there’s so much out there. How do we know whom to trust? At the Commonwealth Fund, my colleague, Eric Schneider, has been answering questions via email every day. Eric is senior vice president for policy and research and is also a doctor, so we’re lucky to have his advice. But this episode is for those of us who don’t have an Eric. I’ve asked him to talk about what we know so far about COVID-19 and what we don’t.

Eric, welcome to the show.

ERIC SCHNEIDER: Thank you, Shanoor. It’s great to be with you.

SHANOOR SEERVAI: All right. Let’s just get started and tell me what we know about the coronavirus pandemic at this point, the last day of March.

ERIC SCHNEIDER: Yeah. There’s a lot to say here, but I’ll keep it brief. We know that the pandemic is a result of a virus, SARS-CoV-2, that it is spreading through the populations worldwide in multiple countries, almost every country. And that in the United States, the pandemic has reached several cities, but that we’re still at the very early part of the pandemic in terms of the number of people who will become infected, will need hospital care, and will die.

In particular, New York City has emerged as one of the leading hotspots. Seattle had the first cases, but they have managed to bend the curve. In New York City, we’re seeing an explosion in the number of cases right now and New York accounts for at least 40 percent of all the cases in the United States at the moment.

SHANOOR SEERVAI: As we see this explosion of cases, I imagine that the information we have is changing by the minute, by the hour. In these places that are badly hit, what do we know so far? What can we trust?

ERIC SCHNEIDER: I won’t even try to give you numbers because they’ll change before we finish this podcast. What we’re seeing is, in New York at least, that the health care system is becoming overwhelmed quickly even though we’re still early and maybe as much as days or weeks from the what’s called the apex or the peak of the epidemic here in New York. We’re expecting that some of the capacity expansion will help. We’re also deeply hopeful that the social isolation, physical distancing that started two weeks ago will actually start to show some slowing of the transmission. But we know we’re in for a very hard time in New York. Health care workers are under great stress even though we’re just at the beginning.

SHANOOR SEERVAI: Let’s dig into what you described as social isolation and physical distancing. What do we know about that and its effectiveness?

ERIC SCHNEIDER: An important point about this virus is its reproductive rate or its transmission rate. For every infectious disease, every organism or virus has a transmission rate. For this particular SARS-CoV-2, that transmission rate is 3 or roughly 3, maybe a little less. That means that for every one person who’s infected, three people will become infected. That’s what accounts for the exponential growth in the number of cases. Each person infects three more people. It’s not as infectious as measles or tuberculosis. They have reproductive rates of 12 and 10, respectively. It’s much less infectious than those or contagious than those, but it’s still too much.

What we know about physical distancing is that it can reduce the rate of transmission. We want to get that rate below 1. We’re not quite there at this point. It’s still close to 2.5 or 3. But with physical distancing, people keeping six feet away from one another, people not traveling, staying at home and going out for only essential chores and tasks, then we can get that rate down. Seattle’s already demonstrated the ability to bend that curve as did Wuhan, China, and South Korea.

SHANOOR SEERVAI: How have they bent the curve by practicing physical distancing as you describe, this six feet distance, and only going out for essential reasons, right?

ERIC SCHNEIDER: Yeah. I think in Wuhan, they actually took it all the way to the extreme of nobody leaving their house under any circumstances. They even went to the extreme of delivering food to people, but really emphasized the total ban on traffic, total ban on outdoor activity to keep people separated from one another.

SHANOOR SEERVAI: What about in South Korea or in Seattle?

ERIC SCHNEIDER: In South Korea and Seattle, they also have practiced stay at home and social distancing. They did that early. It’s actually also important to do testing. South Korea’s strategy has been tied to testing and identifying people with infection and moving people who were infected to separate them from the general population, to either dormitories or large field facilities. Only by separating people with infection from those who don’t have infection can one really shut down transmission of the virus. Everyone of course should be practicing hand hygiene. Washing their hands frequently, especially when they come back home if they go out. We know that masks work when people go outside. How well they work is still not entirely defined. They have to be worn by people who are sick. That’s sort of the key.

SHANOOR SEERVAI: I feel like I, for the past couple of weeks, have been seeing a lot of don’t go out and stock up on masks like you don’t need to be wearing a mask. I don’t have any masks and I don’t know where I would get one. Let’s say, when I go to the grocery store this week.

ERIC SCHNEIDER: The thinking has evolved and this is typical now of everything that’s happening with this pandemic. Two weeks ago, three weeks ago, I would have told you that physical distancing was not a step we needed to take, yet that changed within days. A little as a week ago, I would have told you people shouldn’t wear masks unless they’re sick. I think that’s probably still right that people shouldn’t wear masks unless they’re sick, but it’s because in the U.S., we don’t have enough masks. Just as you said, I don’t have masks in the house. If I went out to get masks, I’m sure I would not be able to find them. Masks really need to be for health care workers. We know that actually the hand washing and the respiratory etiquette, coughing into your shoulder, that can actually go a long way toward protecting individuals.

The reason that the CDC [Centers for Disease Control and Prevention] right now is considering whether everyone should wear masks when they go outside is because it creates a norm. In other countries, this has been effective. Most people, if they’re feeling sick, don’t want the stigma of wearing a mask when they go outside. Many people will just say, “Well, I don’t want other people to know I’m sick so I won’t wear a mask.” But if everyone’s wearing a mask, that’s the new normal and not wearing a mask becomes odd. That’s a way of ensuring that people who are sick or have symptoms will wear a mask. That’s much more effective at protecting the rest of us than having all of us wear masks and hoping that we will protect ourselves by a mask. It’s a bit paradoxical. I can wear a mask outside if I’m healthy, it won’t do much to protect me because I’m still breathing in. But by reducing the aerosol droplets coming away, off of sick people, everyone else is protected.

If we get an adequate supply of masks once we’ve taken care of our health care workers who have no choice but to wear masks. Once there’s an adequate supply of masks, I think it will be very sensible for everyone to wear masks.

SHANOOR SEERVAI: I wanted to spend a little bit of time talking about the point you just raised, supplies for our health care workers and supplies in general of our health care system as a whole. In New York, we now have a ship in the harbor. I haven’t seen it, but my understanding is that we have a field hospital in Central Park. What’s going on there?

ERIC SCHNEIDER: A couple of things are happening. The ship in the harbor is with us to decompress the hospitals by taking all of the patients who need to be in the hospital but not because of COVID-19. What we’ve seen in other settings is that when you bring patients together in hospitals, they transmit infection to one another because they’re in close quarters, nurses are moving around, other staff are moving around through the facility. Taking people without COVID-19 and having them inside of this hospital ship is a much better situation.

The field hospitals, it’s still evolving as to how those will be used. In other countries, they’ve used those as triage stations where people can go to get tested, to be isolated. It’s a form of diversion away from the hospital. There are also some interesting advantages to outdoor field facilities that we learned about in 1918 when the influenza pandemic struck Boston. Boston actually set up field hospitals — tents in the fields — where they brought sailors off of ships where there were infectious and put them in these field hospitals. It turns out that open air ventilation and sunlight are actually pretty effective at reducing transmission of viruses. We may see more of these tent facilities sprouting up, especially in New York as we race to expand capacity, but also put people in settings where they’re most likely to be safe and not transmit the infection to others.

SHANOOR SEERVAI: On this point about sunlight, do we know anything about what’s going to happen as the season changes? We’re in spring nearing towards summer.

ERIC SCHNEIDER: Yeah. There’s a great hope that the seasonal pattern that we see with influenza, more active in the winter, less active in the summer, may help us in terms of this pandemic. The jury is out. We don’t know for sure what will happen. There’s every possibility that transmission will continue despite the ultraviolet light, despite the warmer temperatures, and despite the fact that people may be moving around outside, which is somewhat safer than being inside. Although, currently that situation is strange because we’re all staying at home. It’s not like we’re going to go out to avoid the infection. We really should still be staying at home. We really don’t know the answer to the question of whether, in this particular moment, the virus will sort of go into hiding for a period of time because of warmer weathers and sunlight. That actually happened in 1918. There was a spring outbreak followed by a summer that there wasn’t much activity of the influenza, then it came roaring back in September. We will just have to see. There’s no way to predict that right now.

SHANOOR SEERVAI: You bringing up the pandemic of 1918 makes me think that this isn’t the first time that we’re seeing a global pandemic. What are the other lessons that we can hold on to, look to for hope as we face the COVID-19 pandemic?

ERIC SCHNEIDER: Pandemics are thankfully rare, but not that rare. There have been several epidemics and pandemics that we can draw experience from. One is 1918. The first thing I would say as we know about pandemics is that they can be managed and they do end. New York didn’t actually shut down businesses during the 1918 pandemic. Actually, they enforced rules against congregating, too many people in one business, they kept the subway open, but they told people to stay apart from one another and wear masks. They even heavily enforced rules against spitting. They would fine people. They would bring them to court and fine them for spitting. There are techniques for managing. Even in the absence of antivirals and antibiotics and vaccines, none of which existed at the time.

I have a personal experience having done my medical training in the 1980s in San Francisco at the height of the AIDS epidemic where we were dealing with an infectious agent. We didn’t know what it was. We didn’t know how transmissible it was. We were taking care of people, young men who were dying with no treatment available. It was hard. It was frightening. Health care workers didn’t want to be there, but we got through that. Reminded the other day that I had a patient, when I first started practicing in Boston, who tested positive for HIV, a young woman. I told her what I thought was a death sentence. When I stopped practicing 25 years later, she was still my patient. We know that treatments will become available. We know that we will be able to get control of this epidemic as we did with others. It may take longer than we want. There may be deaths that we certainly don’t want, but we know that there will be an end to this pandemic. We just want to get there quickly.

SHANOOR SEERVAI: As we’re trying to get there, we’re all adjusting to a new way of living. Again, many of us are fortunate to be able to work from home. There are many people who are not able to work from home and have lost their jobs.

ERIC SCHNEIDER: Yeah. This new way of living is the piece that’s most vexing and most hard to predict. We know that the physical distancing can work. We know that now, thanks to virtual technologies, many of us, but not all of us, can do work from home. But the economy is really threatened by the shutdown. This is the equivalent of putting a patient in a coma in order to protect them when they have infection of the brain or something equivalent to that. This is an economic shutdown that is unlike anything the globe has ever seen.

The economic fallout from this and the political fallout are very hard to predict. This is unprecedented. We don’t really know. We don’t have a playbook. We have a playbook for pandemics. We don’t have a playbook for this level of global economic shutdown. In particular, the consequences for the most vulnerable among us are going to be dire. Daily wage laborers, gig economy workers, the people who run restaurants — all of that economic fallout is hitting some groups much harder than others. The government just has to step in to keep the patient alive while in the coma.

The second consequence that I think we’re still trying to understand is the social isolation that this creates. There are distressing stories of patients ending up in the hospital, people in nursing homes who have no visitors anymore because they’re prohibited from having any contact with others. Those are heart-wrenching stories. Unfortunately, they’re just the tip of the iceberg in terms of the potential effect of social isolation.

SHANOOR SEERVAI: I can’t help but wonder what the health consequences of some of this isolation can be. We know that social isolation under ordinary circumstances, maybe I should say before COVID-19, was actually bad for people’s physical health anyway. How does that change in the face of a pandemic?

ERIC SCHNEIDER: Yeah. What a pandemic does in general is it magnifies whatever disparities and whatever problems already existed in a health care system. We have much research demonstrating the bad health effects of social isolation, the health effects of being poor, the health effects of lacking health insurance is estimated, before COVID-19, that 18,000 people in the United States died because they lacked health insurance every year. All of these problems are not unfamiliar to us. We have good studies showing that people with social isolation have health problems. People who are poor have health problems. People who lack health insurance have health problems. Those poor health outcomes, we can project that all of that will get worse because all of those problems are magnified in a pandemic.

SHANOOR SEERVAI: When we talk about the most vulnerable, you mentioned daily wage laborers, gig economy workers. Weren’t they the most vulnerable? Even, again, before this happened, as you’re saying, we’re seeing magnified effects. What is going to happen to them?

ERIC SCHNEIDER: Well, the government is stepping in. Whether it’s doing enough, I don’t think anyone knows the answer. I think most economists believe that the first $2 trillion that is being pumped in as a rescue package is probably not enough given the scale of what we’re shutting down. For people who lack health insurance, Medicaid is an option if that’s available. The health insurance marketplaces are open for people if they have money to buy health insurance. I think we may get to the point where we’re actually just giving people public coverage regardless of their coverage because we can’t afford to have people lacking access to health care in the midst of a pandemic. That will just amplify the pandemic itself.

There are ways that individuals can help. I was just thinking I might be due for a haircut soon and realized I should do my part and send the cash for the haircut to my hairdresser. I think we should all think about the people around us who don’t have access to a regular salary or steady wage or are unable to work for whatever reason and see if we can keep some of that economic activity going.

SHANOOR SEERVAI: On that point, as we’re all staying at home, I haven’t been ordering too much takeout. I’ve been doing more cooking and more grocery shopping than I do when I’m usually out and about working, going out with friends after work. Should I be getting more takeout?

ERIC SCHNEIDER: That’s a difficult question. Takeout is safe in general. People who are doing delivery are, from what I can see in New York, I’ve been out there picking up my takeout. From what I can see, people are following the distancing precautions. Gloves and masks are part of it. The precautions are the same precautions used for anything you’re bringing in from outside your home. You really essentially have to create a decontamination chamber at the front door. Wipe everything down before you bring it into the house. Wash hands before going back into the house. And then, to the extent, you have a delivery person arriving at your door, slip the money out the door and then wait for the delivery person to leave before you pick up the delivered box. That’s kind of the way to separate from the outside world to protect you and to protect the delivery worker. Those little steps done frequently and over and over again can keep a household safe.

SHANOOR SEERVAI: What can we do besides some of the things you’ve already talked about, of course physical distancing, hand washing, hygiene, just to keep ourselves safe and sane?

ERIC SCHNEIDER: I think it’s very important in this situation that people try to maintain as normal a schedule as they can. Wake up at the same time every day. Go to sleep at the same time every day. Try to have one to two hours before bedtime to disconnect from news, to focus on other things. Fear and anxiety are part of the biggest challenge potentially of this kind of pandemic and reducing that so you get a good night’s sleep. Eat regularly and even exercise to the extent that it’s possible to exercise in the house. Or in most stay at home orders there actually is an exception for going out to exercise if people can do that while maintaining social distancing.

I think that’s — really focusing on the opportunity to stay healthy, keep a regular schedule, keep focused, and avoid fear and panic. Those are all important steps. Because the mental health consequences of a pandemic can be a fairly severe for everyone. Isolation is difficult under the best of circumstances. For those who are feeling vulnerable, reaching out virtually either by telephone or if a computer is available, keeping in contact with others through those means really can be very helpful. We had a virtual dinner party with friends living in other parts of the country. People are taking online meditation courses, online yoga. There are options out there for connecting with other people in this difficult time.

SHANOOR SEERVAI: All right. Well, this has been really helpful, Eric. Thanks so much for joining me.

ERIC SCHNEIDER: Thanks. It’s been a pleasure talking with you today and socially connecting here.

SHANOOR SEERVAI: I’ll talk to you soon.

Thanks everyone for listening. I hope this conversation has answered some of your questions. If you have more or want to know what my colleagues and I have been asking Eric, visit thedose.show/cqc.