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The tragedies we see playing out in Italy and around the world are why most public health officials say it’s far too soon to plan when people can return to work. But President Trump says he wants to see much of the country back to normal by April 12. Paul Solman speaks with True Health Initiative’s Dr. David Katz, and William Brangham talks to Marc Lipsitch, a Harvard University epidemiologist.
The tragedies we see playing out in Italy and around the world are why most public health officials say it's far too soon to plan when people can return to work.
But President Trump today said that he hopes to see much of the country reopen by Easter. Other voices in business have made a similar, but less time-specific, call to revive the economy.
We are going to examine those questions now with a pair of conversations.
First, Paul Solman looks at the general case for easing the shutdowns sooner.
Dr. David Katz wrote an op-ed piece for The New York Times last Friday that's received enormous attention, arguing that we may be shutting down too much of the economy too soon.
He joins me from his house in Connecticut.
Dr. Katz, welcome.
Thank you, Paul.
What is the basic argument?
I think the best way to explain what I'm concerned about here is to talk about my parents.
My parents are both 80 years old, generally in good health, but in clearly — no matter how we risk-stratify for preventing spread of coronavirus, they're in the high-risk group.
And when I talk to the two of them about what they're most worried about, my dad, who is a cardiologist, who, by the way, still sees patients at 80, his primary worry is the loss of his life savings and his legacy.
Everything he's worked all these decades to build for his family, he's watching it evaporate and vanish. And, yes, he doesn't want to get coronavirus and die, but, frankly, the loss of his life's work is his greatest concern.
More than his health?
I'd say, what is the thing that worries you most? Well, I don't want to get coronavirus, but, honestly, I'm gravely preoccupied with the loss of everything I have worked my whole life for.
My point is simply this. We must do everything possible to minimize the direct harm of the coronavirus. And that means, right now, protecting everybody from everybody.
But what I argue for is, can we use this initial period to identify high- and low-risk groups, so that the long-term interdiction, the longer-term, is limited to people at high-risk of severe infection, and we potentially can de-isolate, if you will, a major portion of the population relatively soon?
But you're not telling me, not telling us that we shouldn't be social distancing, are you?
What I'm saying is, by all means, we take full advantage of this initial period of social distancing for all. But the goal would be, minimize the harms directly attributable to this bad pathogen, but also minimize the harms of destroying peoples' life savings, ravaging the economy, because, when you think about social determinants of health — and they're very important to me and prominent in my work all these years — you really can't unbundle what happens to the economy at large and what happens to people's health.
But we don't really know the numbers, right?
I was just looking at this issue of, how bad is this, relative to things that kill people every day?
A population like Italy, yes, this is terrible, and all these deaths are concentrated. But it's 50 million people in Italy, and about 1 percent die a year. That's 500,000 deaths a year in Italy before coronavirus. That's 1,500 deaths a day.
We're just riveted on the deaths from coronavirus in a way that distorts the impact it's having on the population. Germany and South Korea went out and found the mild cases, and from both of those countries, the data say, 98 percent to 99 percent of all infections are mild.
We have no reason so far to think that's any different here in the United States. So, can we ramp up our assessment of cases in the population, figure out how many people have this, not just the ones with severe infection, differentiate on the basis of risk, and can we say, two weeks from now, three weeks from now, we have now been able to identify the 75 percent, 80 percent, 90 percent of the population that actually is at no higher risk of severe infection from coronavirus than from seasonal flu?
And we don't shut down our society every year for seasonal flu. So those folks can go back to school, can go back to work, can reboot the economy. And we are going to now be able to essentially concentrate our protective resources to that smaller segment of the population most prone to severe infection, so we do an even better job of providing them all the services they need and protecting them.
Risk stratification means testing everybody, right?
Yes, widespread testing, absolutely.
But America is nowhere near being able to do that.
Well, we're ramping fast.
So, for example, New York, which was testing about 1,000 people a day, in a very short period of time has ramped up and is now testing more than 10 times that many. In fact, I think it's 15 times as many. They're above 15,000.
I think other states obviously can do the same. And I think we can massively improve our detection.
One of the things you said in your article was that you worried about college kids being brought back home, right?
Yes, and I will confess something to you, Paul. I don't feel great right now.
And I have actually arranged to get a test ordered. I have been achy for several days. I don't know if I have had fever or not. I haven't been able to catch it. But I felt like it's been intermittent.
And if you feel like you have got a viral illness in the middle of a pandemic, that's sort of, if it quacks like a duck, it flies like a — right? So, maybe I have this thing.
And if I do have it, my likeliest source of exposure was three of my adult children being sent back home, two from Boston, where they were attending university, and one from New York City, where she was working, and her business laid her off because it shut down.
You know, healthy young people from college and working in New York City, if they get sick with this bug, they may barely notice. Maybe it's not so great to have them infect their nearly 60-year-old parents or their 80-year-old grandparents.
I think we can do a better job of separating high-risk from low-risk, and treating those two populations differently. And I think a world of good could ensue from that.
Dr. David Katz, thanks very much.
And an important note: Paul recorded that conversation yesterday evening.
This afternoon, after the president's press conference, Dr. Katz said the decision about when to return must be data-driven. He tweeted that — quote — "An arbitrary back-to-business deadline is dangerous folly."
Other officials are alarmed by timeline as what the president has discussed.
And now William Brangham speaks with a leading public health voice who has warned of the real risks of bring people back too quickly.
For that, I'm joined now by one of the nation's leading epidemiologists.
This is Marc Lipsitch with the Harvard T.H. Chan School of Public Health. He also specializes in infectious diseases.
Marc Lipsitch, thank you very much for being here.
I know you saw that or heard that prior conversation that Paul Solman had with David Katz.
And I want to talk about this argument that seems to be gaining some currency, that the economic pain of what we're doing to prevent the spread of coronavirus is too much to bear, that it is too much in comparison to the virus.
What do you make of that?
I think what is clear is that there is going to be a lot of economic pain.
And I think no responsible epidemiologist, because we also care about other kinds of disease and suffering, would try to minimize that.
The issue is that the size of the pain that we're feeling from the virus now is growing exponentially. The purpose of social distancing is to slow the spread and, ideally, turn over the curve of the epidemic, so that we don't end up with more cases of disease than our health care system can handle.
One tricky part about this is that the actions we take now will bear fruit in three weeks or so in reduced caseloads in our intensive units. That's how long it takes for someone to get sick enough to need intensive care normally with this virus.
So, it's not that we can wait until we feel the pain to take action. If we do that, we have three more weeks of increasing burdens on our health care system, which will crush it.
Katz and others, including the president even today, have been arguing also that the majority of cases thus far appear to be relatively mild and that draconian efforts to stop what are a majority of mild cases is inappropriate.
You know, the majority of people don't die in any war, but we still try to stop wars.
And the — this is just not a relevant comparison. If some tens of percents of a population, maybe a majority of the population, gets it, of course most cases are mild. Nobody disputes that. The issue is that many cases, in terms of absolute numbers, are going to be severe. That's first problem.
The second problem is that the numbers of those people, as we have seen in China and in Italy and in Iran and are beginning to worry we're going to see in New York City and elsewhere, there are enough of those people, so that the whole health care system is unable to take care of the cancer patients and the heart attack patients and the people who are in the hospital for all the other reasons.
It seems that the argument that you're making is that we, on some level, suffer this economic pain now, but we don't necessarily see the benefits in reduced cases for quite a few weeks.
It's similar in some ways to the argument that's made about climate change, that sacrifices and changes to our energy infrastructure need to be made now, but we don't see the benefits from that until maybe years down the road.
That's a very difficult thing, I think, for people to swallow.
Well, I think it may be, and I think our political leadership has encouraged a feeling of, we should privilege the present over the future.
It's just not responsible. Leadership means that, when there is a problem, you encourage the people to sacrifice what's needed to have a better outcome in the future. It's not that we're sacrifice now so that someone else has a better outcome. It's really so that we have a better outcome, so that we have a health care system a month from now.
It shouldn't be that complicated to get that message through.
So that we have a health care system a month from now. You see that this is really that dire?
In some places, it's going to be in a month. In some places, it may be less — it may be longer than that.
But New York City, for example, is taking measures right now, and sacrificing a lot in order to make sure that their intensive care units are functioning as well as they can be the next few weeks even.
So, some places, it will be more than a month, if we do nothing, but not much more than a month, because this is an exponentially growing phenomenon.
President Trump seemed to indicate today that he pointed out how we this lose tens of thousands of people to seasonal influenza every year. And he says, we don't shut down the country for seasonal flu.
He seems to be optimistic, in a sense, that the death toll, while large, will not be so tragic for COVID.
And does the epidemiology indicate that that optimism is right?
Well, the projections are for a much greater toll than for seasonal flu, for two reasons.
Every year, somewhere around 10 percent or 20 percent of the population gets seasonal flu. And the expectation is that, especially if uncontrolled, this epidemic will infect more than half the population. So, there are more people at risk. And the death rate from this is somewhere in the neighborhood of 10 times that from seasonal flu per case.
It may be more. It may be less. There's a lot of uncertainty around that number, but it's considerably more than for seasonal flu.
So, it's just not responsible to say this is the same as seasonal flu. It's going to get more people infected, and it's going to be fatal and severe in a higher fraction of them.
The other thing to say about seasonal flu is that we have never seen intensive care units in multiple countries shut down, multiple advanced industrialized countries, shut down and unable to function because of seasonal flu.
It's just not what happens.
All right, Marc Lipsitch from the Harvard T.H. Chan School of Public Health, thank you very, very much for talking with us.
Thank you for having me.
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