Like many of you, I’ve been consuming Covid 19 news and podcasts voraciously and non-stop for weeks. I’ve even taken to watching…watching…actual news. Like, on the TV. Mostly Anderson Cooper, none of the pundits, and obviously not the ridiculous Trump rallies, er, nightly State(s) of the Union or whatever. I’ve listened to updates from medical experts, economic advisers, political experts, authors, actual interviews with victims and healthcare providers, psychologists, frontline workers, business owners, you name it. This is all part of the new normal. All while navigating the fraught SBA loan process and waiting to see if we will still be in business when all is said and done.
When I read the comments on NextDoor, basically the definition of hell, what I see is a bunch of people who don’t know much but whose fears fall squarely along partisan lines. They can’t read stats critically. They can’t read articles past the headline. They don’t know why some of the stats don’t mean what it sounds like they mean. They lack basic comprehension and critical thinking skills, but what they lack in these things, they make up for in self-righteous lambasting of the opposing view. Oh, the humanity!
The problem is, nothing we are doing is really a plan. Nothing we are doing so far (nationally, some states are better) is necessarily going to make it safe to re-open the country. That’s because we don’t have the information we need. We sometimes think we have some information, and then it changes, and we realize we don’t really know what we think we know.
- Number of cases. What we know is the number of people who have tested positive. What we don’t know is the potentially large number of people who were positive who were never tested. As a result, we can’t know how many people have had it, how many have it now, or how many have recovered. We don’t have enough testing to know who these asymptomatic carriers are who have the ability to infect others or how many of them there are, or how long they can infect others. People can’t get tested if they don’t have symptoms, and they usually won’t even ask for a test unless they are very sick. We’ve been told they can spread the illness for 3-4 days before any symptoms happen. So the biggest gaps here are:
- People who couldn’t get a test in their state due to lack of availability.
- Asymptomatic people.
- People who chose not to get a test 
- their symptoms were mild
- they don’t know they were exposed
- they were uninsured
- they don’t live near a testing facility
- they need to work and don’t want to be told they can’t
- they just didn’t think they needed a test or didn’t want to get one
- Number of hospitalizations. What we can know is the number of people who were actually admitted to the hospital with Covid 19. This doesn’t include people who can’t be moved, like those in nursing homes, and it doesn’t include people who aren’t insured who won’t go to the hospital. It doesn’t include people who just stay sick at home, possibly dying there. But this is at least directionally helpful information since we know it doesn’t include all cases. It is one indication of how many cases are severe.
- Number of deaths. This is mainly going to be the number of people who were known to have Covid 19 who died while still hospitalized or under a doctor’s care. If they died in isolation at home, they may not have been reported. If they died early and had other health issues, their deaths may have been miscategorized as something else. There’s been a lot of controversy around the death numbers in NYC being revised upward recently, and the reason for that consternation is that there are different reasons to want to know it. Do we need this data to understand the spread and impact of the disease or to gauge when it’s safe to reopen the country? We don’t have good data around Covid 19 deaths that had a co-morbidity factor. We don’t know how many people died (or recovered) after being tested who did so in a place other than the hospital. And, since we don’t know who all has it, we can’t know the correct death toll for those who are outside of a hospital. At best, this is a directional number.
The only factor that we seem to be evaluating in terms of getting the country back to “normal” is the hospitalization case load and death toll, but without knowing the total spread, we can’t know if there will be a spike in cases if we start eating in restaurants or going to the movies again. My first post on this topic recommended we do random tests in the population to better understand asymptomatic spread. On March 26, I made several reasonable suggestions to get ahead of the novel coronavirus. Many of these were adopted in some form or other or in some parts of the country. Two that are vital have not been widely addressed, and they are at the heart of what we need to do to get back to anything resembling normal:
- Testing. The biggest gaps here are 1) many states still don’t have adequate testing available (Utah is ahead on this one, but AZ is just terrible; this is because Utah has companies that can provide testing, and AZ doesn’t have any of these types of businesses), and 2) nobody is testing the asymptomatic population at random to better understand the real spread of the illness. In Utah you have to have at least one mild symptom. In AZ, you have to have at least 3 severe symptoms for a prolonged period, and be willing to sleep with the test giver.
- Contact Tracing. You have to be able to link cases to find out who has contracted the illness even before they start exhibiting signs, similar to what they’ve done in places like Singapore and South Korea. All citizens in those countries download a free contact tracing app that will track the other cell phones that are in proximity to theirs. In the US, contact tracing is a manual process. A person who tests positive has to provide names and places for contact tracing, which is the process used to notify people who were exposed to an STD. Then someone makes personal phone calls to those contacted to notify them they should watch for symptoms and get tested if they have symptoms or stay quarantined for two weeks. One obvious gap is who knows what people you were near before you were symptomatic? This isn’t an STD where only people you’ve had sex with are at risk. You don’t know who was on the subway near you or whom you passed in the grocery store! The apps that were created in Singapore track your “contacts” based on the proximity of others’ phones to yours using the bluetooth technology that already exists in the phone. It does require people to opt in, even in Singapore. In the podcasts where I’ve heard this discussed, even the interviewers are squeamish about the idea of using a phone app to track contacts, but without it, our solution is impractical and deeply flawed. I get that Zuckerberg has pretty much ruined any trust we ever had in big tech, but if it means movies and Costco samples, I am willing to download the app now, while reserving the right to litigate him back to the Stone Age at a later date.
First Outlandish Idea: the Calls are Coming from Inside Your Phone
Let me expand on the idea of a contact tracing phone app and how it might work (in conjunction with testing). To enter restaurants, movie theaters, and stores, you require that patrons scan a QR code they have on the app at the entrance. Their code must be “green,” meaning that they have not tested positive and they have not been in proximity with anyone who has tested positive. If someone is tested positive, the app immediately changes the QR code of those they were in contact with anytime up to 4 days in advance of their symptoms to a “yellow” status, meaning that they need to be tested and cleared before their code is green again and they can go to public places. A red QR code means you are currently infected and must be fully quarantined. It’s a solution that still requires a lot more testing availability than the US has managed, leaving it up to individual states to try to figure out their own testing. That doesn’t work as well in some states that don’t have those types of companies, which is why we should be using the Defense Act to ensure all states have an adequate number of tests. Leaving it all up to governors is destined to result in a mish-mosh of halfway solutions. So that’s one of my two “outlandish” ideas: use phone apps and testing to reopen stores, movie theaters, etc. to anyone who is “cleared” with a clean QR code.
Second Outlandish Idea: Pandemic Duty
Which brings us to my next outlandish idea, and this one is truly going to sound dystopian. If you didn’t like the “big brother” aspect of the last one, this next one is going to sound like Logan’s Run or Shirley Jackson’s short story The Lottery. Social distancing for a prolonged period was designed to “flatten the curve” so that we didn’t overrun the capacity of hospitals and medical staff. The problem in many states, including the one I live in (Arizona) is that we are not utilizing the full capacity of the health care system yet (aside from our absolutely inadequate testing here). We have only been filling about a third of our hospital beds in our state. If the curve is too flat, it takes longer for the illness to peak and run its course. The disease is still out there because it has such a long incubation and infection period, but we are just slowing down how long it will take to develop herd immunity and for the disease to evolve to something less deadly. Social distancing is meant to contain and reduce the spread, but the disease still spreads, just more slowly. Well, what if we used the jury duty selection process and used our hospitals to full capacity rather than waiting for nature to take its course? As with jury duty, you can allow exemptions based on specific co-morbidity factors and risks (even for the uninsured, you could run a panel of co-morbidity tests to “qualify” someone for pandemic duty). Then, if we can ascertain that recovery makes one immune (or enough immune to be safe to return to work), those who complete their duty return to work and are available for any job duty that is needed.
Don’t get me wrong, I know why we aren’t doing this one. Some people we think are healthy have died. We don’t have a good handle on why that is. Nobody wants to sign up to get sick (or for jury duty, for that matter, which is how I got this idea–I got a jury duty notice in March for April duty). And no politician wants to have to explain to a family why the government killed their loved one for the public good. This one would be about as popular as the draft. and I can just imagine the interviews with grieving families that would hit the media. The only practical way to do this one is if compulsion were off the table and if it was so easy to get out of pandemic duty that it was really voluntary. Maybe you could compensate people for agreeing to it, but you’d have to pay much better than jury duty does.
On the upside, we would know a heckuva lot more if we had taken this approach. How many people would get it and have really light symptoms? How many would be completely asymptomatic? For those who did get sicker, we would have them under observation with medical staff on hand and be able to evaluate what the disease did and what their other issues were. As they say, the best defense is a good offense. And let’s be honest, shutting down the economy, which would basically happen anyway, is totally compulsory and hurting a lot of people (as well as socially enforced). Regardless, this is at minimum a great plot for a movie if we are ever allowed to go to the movies again.
 I know someone who has several symptoms but she is uninsured. I read that Banner Health is administering tests to those who are uninsured and gave her the information. She went and explained her symptoms, and at first they said they wouldn’t give her the test without a doctor recommendation (which she doesn’t have because she is uninsured). Then they said they wouldn’t give her the test unless she was sick enough to be hospitalized (which she would never agree to because she is uninsured). So they just said to stay home for two weeks. She is not included in AZ’s Covid 19 numbers because she hasn’t been tested. Our state likes to tout how few cases we’ve had, but we literally don’t know how many have had it!
 OK, so that’s probably not true because the test giver doesn’t want to get infected.
 A virus that kills its hosts is a less successful virus than one (like the common cold or the flu) that just makes us sick, then we get well but we can be infected again. That’s the goal of any self-respecting virus, not killing its hosts and ending up dead with them.