They say that hindsight is 20:20. While the spread of COVID-19 is a problem we will have to continue to deal with, right now we have the benefit of some hindsight to learn from our policy response so far, and apply them to the future.
In January and February, the public largely did not pay serious attention to COVID-19 while policymakers hoped it would go away. But once China locked down the city of Wuhan and hospitals were overwhelmed in Milan, policymakers were shocked into action.
Throughout the US, states responded with shelter-in-place orders and forced businesses to shut down, except those that individual governors deemed “essential.” The response was heavy-handed, but the dangerous nature and quick spread of COVID-19 required a strong response. Whether the details of the response were necessary is debatable.
At the time, we knew that COVID-19 had exponential spread. This means that each infected person would spread it to multiple other people, and by the time we would notice the spread, it would be too late to stop it. This threatened to overwhelm our hospital capacity, which would further increase the death rate.
Poor testing left us blind to the early outbreak and its prevalence in the community, allowing it to spread undetected. Early estimates of the reproduction rate, the number of people each infected person will infect, ranged between 2 and 5. The case fatality rate, the percentage of confirmed infections who die, was estimated to be as high as 5 percent. This is much deadlier and easier to spread than the flu, despite all of the comparisons of the two illnesses.
Testing efforts were stymied by the FDA for months. We still lack the testing required to get an accurate number of cases, but the current estimates for the reproduction rate is just above 1. The case fatality rate is currently estimated to be around .25, but has continually fallen since the beginning of the pandemic.
Once community spread became apparent, state and local public health officials focused on non-pharmaceutical interventions (NPIs). These interventions seek to reduce transmission through changing peoples’ behavior. They could take the form of shelter-in-place orders, business closures, or less restrictive policies.
Because of differences in local conditions, population size, time spent indoors, and other characteristics, one-size-fits-all NPIs will vary in effectiveness. In a recently published NBER working paper, the authors found that in Texas, over 90 percent of the reduction in COVID-19 deaths from NPIs were caused by the orders in large urban areas. There was a small reduction in deaths from NPIs in rural areas and the later statewide shutdown orders.
NPIs are dependent on changing individuals’ behavior, so the rural NPIs may have also suffered from a lack of buy-in from the residents. For communities with strong social ties and frequent close interactions, social distancing is more difficult. This also makes it more difficult to continue for long periods of time. Another NBER working paper found that less social distancing occurred in communities with strong community engagement.
Additionally, the risk of severe symptoms and death vary widely across demographic groups. Risk profiles change based on age and comorbidities. New research has found that simply targeting lockdowns based on age group was just as effective and far less costly than the blanket NPIs most states implemented. Rather than isolating everyone, states should have isolated those with the highest risk of death, the older population and those with comorbidities. The younger population could have taken precautions, but not sheltered in place.
This also highlights the importance of protecting elder care facilities, where the highest risk patients live. Even now, almost half of US deaths were in nursing homes. This was caused in large part by some states, for instance Pennsylvania, New York, and New Jersey, requiring elderly care facilities to accept COVID-19 positive patients.
So, what lessons can we learn from this?
First, it underscores the importance of tailoring policy to local conditions. Policymakers should rely on county health or even city officials, who have more knowledge about local conditions than state and federal lawmakers. We should focus our efforts on preventing spread where it is most likely to occur. Large urban areas are much more likely to have a higher rate of spread than more spread out rural areas.
In areas where a sense of community and frequent interaction is an important part of life, social distancing will be difficult to continue. Policymakers should work with community leaders, encouraging social clubs, churches, athletic leagues, etc. to find safe ways to interact to help reduce the cost of social distancing. Again, this requires local policymakers to be involved in the decision-making process.
Within communities, we should be sure to take care of the most vulnerable populations. We don’t only have to rely on government for this. My local grocery store, like many others, set aside special times where only the elderly and immunocompromised can shop to protect them.
Finally, we cannot allow bureaucracy to slow down the adoption of new tests or treatments. We need to be able to take advantage of breakthroughs without forcing their creators to go through arcane application requirements that only delay being able to treat patients.
This first wave of COVID-19, and our response, has given us valuable lessons for how to respond to future outbreaks. While combating such an infectious and deadly disease can be difficult, localized policies, targeted to local conditions that are not overly burdensome will help us successfully reduce spread of the disease.
Catalyst articles by Conor Norris