Reentry after the panic: Paying the health price of extreme isolation
With a world-wide sense of relief, progress continues in containing the COVID-19 pandemic. Projections have been revised downward for virtually every major negative consequence of the disease. Few doubt that the unprecedented isolation policies and near-total economic lockdowns adopted by most countries had a significant impact on reducing deaths from the virus. And aside from New York, where almost half of the entire country’s deaths and cases have occurred, the vast majority of American hospitals were not overwhelmed beyond capacity. All of this is terrific news.
But we will now pay a big price. Our policy of total isolation involved trade-offs and left a significant problem by endangering the resumption of normal activity.
One important health care trade-off that must be acknowledged is that we will have lost lives, because vital health care for millions of Americans was deferred or skipped to accommodate potential COVID-19 patients and for fear of spreading the disease. Over two-dozen states and many hospitals stopped “non-essential” procedures and surgery. That included delayed or missed diagnoses — cancer screening, biopsies of now undiscovered tumors and potentially deadly brain disorders like aneurysms and arteriovenous malformations. Treatments for known serious illnesses were also missed. In some centers, 80 percent of brain surgery cases were skipped. Acute stroke and heart attack patients missed their only chance for treatment, some dying and many now facing permanent disability. Cancer patients deferred chemotherapy. Whether right or not, policy decisions had consequences that should not be ignored.
But a bigger price might now be paid from choosing extreme isolation. In the absence of immunization, society needs circulation of the virus, assuming high-risk people can be isolated. Infection itself allows people to generate an immune response — natural antibodies. Given the estimated contagiousness of COVID-19, about 60 percent of people in the community need to have antibodies to stop the spread by “herd immunity.” Remember, medical care is not necessary for the vast majority of people who are infected. We also infer from testing in Iceland and Vo, Italy, that half of infected people are asymptomatic. That has been misleadingly portrayed as a problem requiring mass isolation; those infected people are an important vehicle for establishing immunity by transmitting the virus to the low-risk group. Preliminary testing in Germany shows that perhaps 15 percent of people are immune; no doubt this varies greatly by region. It is very possible that whole-population isolation prevented natural herd immunity from developing.
We now need to reenter normal life. Yet, instead of having a population protected by a naturally developed immunity, we are faced with a perilous decision — how to prevent a second wave when people are free to mingle. We should not wait for vaccines. America’s amazing private sector health care innovators are working 24/7 inventing nearly half of the world’s 100-plus potential vaccines. But these will take many months to be widely available. Moreover, vaccines might have limited effectiveness; for influenza, a vaccine is only 40 to 60 percent effective, according to the CDC.
Continuing full-population isolation and waiting for a vaccine would be doubling down and yielding to panic. Instead, we could institute the focused strategy that some proposed in the first place — aggressively protecting the vulnerable, strictly self-isolating the mildly sick and, with testing, opening most workplaces and small businesses except very large group activities like concerts and sporting events. This would allow enough socializing for the essential immunity to gradually develop among those with minimal risk of serious consequences, while still saving lives and limiting the massive harms of continued total isolation.
Targeted isolation is still critical. High-risk elderly with chronic illnesses, HIV patients and immune-compromised people should be extremely cautious, perhaps until a vaccination can be delivered; they will be the first priority, just as was the case for flu vaccine roll-outs. Younger, otherwise healthy people with mild symptoms should stay home and isolate for two weeks and get tested when it’s available. To protect the vulnerable, antibody testing for immunity and, if non-immune, for active virus, could be mandatory for specific groups of people. Extrapolating from previous recommendations by the Infectious Diseases Society of America, the highest priority testing should include essential pandemic response workers, senior center employees and certain patients — those receiving hospital care for fever and unexplained respiratory symptoms, and all immunocompromised people with fever or respiratory symptoms.
If the most vulnerable are protected, most daily activity could be gradually restored with the broad, verifiable testing becoming available. It is challenging, but not insurmountable, to require a quick, mobile ID verification of immunity or virus-negative status for entry into many private and public establishments, including public transportation, during this transition phase. We already require identification badges to enter many large office buildings and airports; we routinely require proof of age at many bars and restaurants. Perhaps, at least temporarily, this will be the “new normal.”
As the coronavirus spread, so did the contagion of fear, and that fear probably influenced public policy. Many lives were undoubtedly saved, and the great majority of hospitals were prevented from being overwhelmed. But the near-total isolation of everyone and the lockdown on most health care unrelated to COVID-19 must end, because it is harmful to eradicating the disease, and its costs, including actual loss of life, could become enormous.
Scott W. Atlas, MD, is the David and Joan Traitel Senior Fellow at Stanford University’s Hoover Institution, the former chief of neuroradiology at Stanford University Medical Center and the author of “Restoring Quality Health Care: A Six Point Plan for Comprehensive Reform at Lower Cost.”
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