Public Health is Paramount in the Fight Against Coronavirus
Back in early February, both the United States and South Korea were just beginning to grasp the enormity of the coronavirus outbreak that was then ravaging Wuhan, China. South Korea already had dozens of confirmed cases, which was actually more than the U.S. at that time. Yet within two weeks, cases would surge well into the thousands in Seoul, prompting the roll-out of drive-in coronavirus testing centers on an industrial scale. Fast forward to today, and South Korea has seen just 500 total deaths from coronavirus; the United States, over 260,000 as of Thanksgiving. Adjusting for the population difference, the U.S. still has ninety times the number of COVID-related deaths as South Korea. And with about 1,500 dying every day and a record 73,000 hospitalizations nationwide, there seems to be no end in sight. “We are heading into a dark winter,” warns Dr. William Haseltine, a retired virologist at the Harvard School of Public Health and Harvard Medical School.
So, what did South Korea do right? Authorities committed to mass testing and exhaustive contact tracing early on, isolating confirmed cases and using the amassed data to generate real-time hotspot maps. These were then made widely available to help citizens avoid infection. Notably, authorities systematically improved the contact tracing regime throughout the outbreak: BBC (British Broadcasting Company) reporters shadowed Korean health workers during the height of the epidemic, finding that at the outset it took a few days to trace the contacts of an infected case. But within a week, they had managed to shave this time down to less than an hour. This was a decisive factor in containing a disease like COVID-19 for which asymptomatic transmission plays a central role. After all, asymptomatic carriers are by definition healthy and mobile, and hence the most likely to transmit coronavirus; therefore, officials must waste no time getting them off the streets. South Koreans learned this lesson the hard way when so-called “super spreaders” each infected hundreds at crowded churches.
South Korea was therefore able to essentially flatten the infection rate curve in 20 days, opting for targeted quarantines in lieu of mass lockdowns. This is a bracing message for the United States as the nation hits 12 million total cases with a record 73,000 hospitalizations. South Korea’s example proves that it is possible to contain the virus by systematically and relentlessly improving basic public health measures, all while avoiding crippling shutdowns.
Of course, South Korea is a smaller country, with 52 million people. But population density, not total population, is perhaps a more critical factor in the rate of spread of an infectious disease. Controlling the epidemic was arguably harder in South Korea than in the US at the very beginning, as South Koreans are practically living on top of each other: the country is the size of the state of Maine, yet with fifty times the population! In fact, cases exploded into the thousands in February from just a few dozen a few weeks before, despite the fact that authorities had been tracking the disease for a month.
Not surprisingly, in the United States the virus ravaged coastal urban areas first, necessitating lockdowns, and took many weeks to penetrate the hinterlands and affect them to the same degree. But because the virus was never contained, rural areas and the Midwest are now being hit the hardest. As of mid-November, North Dakota had the highest coronavirus positivity rates in the country, at 56% (compare to New York City, which shut down its public schools when positivity rates exceeded 3%). CNN recently reported that the number of deaths in North and South Dakota now exceeds the total number of deaths in South Korea, despite a combined population of just 1 million. Wisconsin, just next-door, was cited by the White House Task Force on COVID-19 for an “unrelenting rise in cases”, calling this an “ongoing health emergency that is leading to increased hospitalizations and deaths.”
Some deterioration in the COVID situation was expected as the weather cooled: cooler weather drives people indoors, reducing ventilation, and it is thought that cold, dry weather itself enhances viral transmission. What is alarming, however, is that we are already hitting record infection rates and hospitalizations with a month left until winter. And of course, 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 CDC; co-infection with coronavirus and flu could therefore be a death sentence. To make things worse, we are on the cusp of the holidays, the busiest travel season of the year. While it is likely that many Americans will pull back on travel this season, many more may be unwilling to change their plans despite the deteriorating situation, if the past summer is any indication.
In short, we now have a confluence of factors — cooler weather, flu season, and the busy holiday travel season — whose impacts have yet to be fully manifest. Meanwhile, we are already in the grips of a severe second wave nationwide. So, it is no surprise that authorities have been banking on the prospects for a vaccine. Pfizer’s announcement this month that their vaccine may be available by the end of the year is therefore welcome news; however, distribution and availability for any of the vaccines will vary by region, and it will likely be months before everyone is vaccinated. “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. And last week, Dr. William Haseltine, a retired professor at the Harvard School of Public Health, said that the pandemic has “no end in sight,” likening the coming vaccines to sheriffs in Hollywood westerns who arrive too late. “No vaccine will save us,” he warns, even if they are proven effective — which won’t really be known until after they are rolled out.
President-elect Joe Biden is more optimistic but seems to share these reservations, repeatedly imploring Americans to wear masks “for the next few months.” Even infectious disease expert Dr. Anthony Fauci, who has expressed enthusiasm about the progress on numerous vaccines, stressed the need to “double-down” on measures like wearing masks and social distancing. Bossert, Danzig and Lawler go further, calling for severe restrictions on social gatherings and the closing down of restaurants, bars and clubs.
Thankfully, these voices are beginning to receive stronger backing from the top. Warning of the “accelerating community spread” of coronavirus, 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 a week after the election. The key is that this must be a coordinated and unrelenting effort, involving the full cooperation of local and federal authorities and the participation of each citizen, if the experience of South Korea is any indication. With its well-organized national public health response, it managed to essentially contain the virus without lockdowns or the evidence-based treatment protocols that we have now.
Some may argue that what worked for a smaller, albeit densely populated, country like South Korea might not apply to a geographically large one like the U.S. But the experience of China, which is about equal in size to the U.S. but has nearly five times the population, suggests that public health measures — if rolled out correctly — may prove the decisive factor even for a large country with sprawling, densely populated cities — like the United states.
Many outside observers attribute China’s successful containment to draconian and authoritarian measures like strict city-wide lockdowns. But back in March, Dr. Bruce Aylward, a physician and epidemiologist who led a WHO mission to Wuhan in February to observe their coronavirus response, told NPR that this “would be taking the wrong lesson.” Lockdowns, he pointed out, “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, specifically 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 concludes 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. This rather unique and unprecedented public health response in China reversed the escalating cases in both Hubei [Wuhan’s province], where there has been widespread community transmission, and in the importation provinces.”
When the report was released in March, many presumed that it was premature or inaccurate, and some even accused WHO officials of bias. But authorities in China have been able to keep the virus at bay ever since, vindicating these global health officers. Tellingly, China has had so few cases since last March that its scientists had to conduct vaccine trials in other countries; with little chance of community transmission in China, it would be difficult to gauge the effectiveness of vaccines. In fact, during China’s Golden Week holiday in October, the Chinese travel site Ctrip logged 600 million trips, reflecting the success 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 turned up COVID-positive in Qingdao following Golden Week, authorities tested every single person in the city — nearly 11 million people. Only nine more cases were found, as reported in The New England Journal of Medicine, which cited the city’s “aggressive contact tracing and quarantine of close contracts.”
While there has been scant attention paid to China’s successful containment program, others 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 opinion 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,” pointing out 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.”
More generally, the successful containment of coronavirus by countries with disparate political systems, like South Korea, New Zealand, and Taiwan (democracies) and China and Vietnam (communist dictatorships), is living proof that containing the virus doesn’t come down to political systems or curbing freedoms but to sound public health practices enacted at the national level. This should be reassuring news as we hit 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 and keep the virus in check.
But once vaccines are finally rolled out, we must not let down our guard. Yes, several vaccine candidates have shown promise in trials but, as Dr. Haseltine noted, their true effectiveness won’t be known for some time after they have been distributed widely. Until then, he warns, we are looking to a “dark winter.” Therefore, we must do all we can now to 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.
