It’s been 100 days since the COVID-19 coronavirus was identified by a medical team in Wuhan, China. We are at a crucial point and it’s important to understand what going forward should look like. Instead of ringing a bell to “reopen” America for business, let’s make sure we continue progress on stopping the epidemic while we are growing the economy.
Our goals don’t have to be just about health or the economy. Both are connected, and there are trade-offs that come with prioritizing each.
There is clear evidence that physical distancing, widespread testing, patient triage and health worker protection, hospital surge capacity, and clear, consistent public communications all work. Even given unknowns now, the science suggests that the COVID-19 response will require continuing work in five streams: mitigation, building immunity, recovery, protection and preparedness.
Mitigation
Our initial focus has been on mitigation: trying to reduce what is already an unprecedented impact by diagnosing and treating those who become infected, and practicing social distancing and hygiene. The search is on for anti-viral drugs and early results suggest that the drug remdesivir may be an effective treatment for patients who are severely ill with COVID-19. We are also scaling up testing for as many symptomatic and asymptomatic people as we can to detect the virus, using RT-PCR tests. We are trying to limit the spread and number of people infected so as to flatten the epidemic curve, not overwhelm our healthcare system and keep individuals healthy. As long as there are still active cases and continuing transmission, we will need to protect high-risk and vulnerable populations.
Immunity
However, as the epidemic continues, massive numbers of people will have been exposed to and infected by the novel coronavirus — and then recovered. This contributes to the next stream, building immunity. Although we don’t know for sure, scientists suspect that people who have been infected by and produced antibodies to the novel coronavirus will have immunity that lasts for at least one or two years. These tests that are done for the coronavirus will be particularly useful in identifying people with immunity, who can move freely and safely and return to work without posing or facing a threat. Clinical trials are now in progress to see if plasma from people with antibodies is effective in preventing or treating COVID-19 infections.
Work in the recovery stream will aim to develop a full picture of who is immune to the disease. Some people will have been infected and not had symptoms. We can identify these people by widespread serologic testing for antibodies. People with antibodies who test negative for the virus could be certified as ready to return to work. Germany and Italy and our own White House Task Force are considering issuing “certificates of immunity” to those with positive serology tests.
Antibody testing will require a lot of tests, but we can make them — both those that look for the virus and those that measure antibodies. The FDA approved the first serology test on April 2 and if it goes into mass production, it might become widely available for as little as $10 a test, as compared to $50 for an RT-PCR test.
Understanding the levels of immunity in our population as a whole will also be helpful for guiding policy. Once a certain percent of the population is immune to a disease, the spread is reduced drastically, a concept known as herd immunity. When the number of new cases is markedly reduced, it will also be possible to identify new cases through contact tracing and contain outbreaks when they occur.
Recovery
Policy changes focusing on recovery will need to consider two goals simultaneously — saving lives and restoring jobs. The public health and business sectors will have to work together. This means those who want to save lives will need to acknowledge that safety comes with an economic cost and those who are focused on restoring the economy will need to resist the lure of securing jobs or votes by moving too quickly, or exploiting resentment against government public health actions. Our goal should be to keep all individuals going, even the most vulnerable. It is not simply a question of maximizing economic value. Sick people cannot work. Children cannot thrive when breadwinners die. Hungry people are not healthy.
Protection
As work progresses on protection, all of those people who have not been infected, especially those in high-risk groups, will need to continue social distancing and scrupulous hygiene until they can be protected with a vaccine, or by a prophylactic medication. The World Health Organization has announced that there are already more than 50 vaccine candidates ready for testing and at least four vaccines are already being tested to see if they are, first, safe, and, then, effective. Producing an effective vaccine may take another 18 to 24 months, even with real collaboration among scientists, government and the private sectors among different countries. We will need a system set up in advance for efficient, effective, and equitable distribution to protect our health workforce as well as our populations. Those who acquire immunity from the vaccine will join those who acquired immunity from infection in contributing to herd immunity.
Preparedness
The fifth stream of work will focus on preparedness, preparing for the next pandemic. This work has already begun. We will need to set up a public health infrastructure that can respond immediately to the next emerging threat by detecting it early, identifying cases and tracing contacts early enough to effectively contain the disease and quickly mobilizing coordinated government responses at federal, state, county, and local levels. It will also need to be ready to quickly test and manufacture vaccines and have stockpiles of supplies and antiviral therapeutics. Numerous scares in the past have led to efforts to strengthen the U.S.’s public health infrastructure. In every case, the effort has collapsed after the threat is over. This could be the first time that a virus leads to a permanent change in our willingness to adequately fund public health.
We are moving faster against this coronavirus than we ever have moved in any previous pandemic. We have every reason to hope and be optimistic.
Mark L. Rosenberg, M.D. is an epidemiologist, infectious disease physician, and psychiatrist. He is president emeritus of The Task Force for Global Health and a former assistant surgeon general. Julie Rosenberg is deputy director of the Global Health Delivery Project at Harvard and a manager at Ariadne Labs in Boston. She is Mark Rosenberg’s daughter.
