The 4 latest questions about Covid-19 (and 3 clarifying follow-up questions)

In this article, I'm sharing information written by my friend, Dr. Greg Jacobson, a practicing emergency medicine physician.

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Tonight I will give you my thoughts on four questions I keep getting asked...

How long are we going to be physically distant? 

I don't know the future but since so many people ask me, I would like to give you my thoughts on how this is going to play out eventually. If you haven't had a chance to read about The Hammer and the Dance yet, I recommend you go read this first. I really like that terminology and visualization, and it is a model that we are hopefully starting to follow in this country. We are not going to be physically distant forever. At one point the cost-benefit ratio of distancing will no longer be in balance. There are costs of remaining 100% distance forever (for instance, the economy will go from a recession into a depression, and there will eventually be widescale social/mental collapse). On the other hand, there is a cost to remaining 100% social (lots of people dying unnecessarily because our healthcare system will collapse). We are going to end up somewhere in the middle. I personally think the Hammer will be in terms of weeks, and The Dance will be in terms of months - if we can get our act together.

Will everyone be on the same restrictions forever? 

This is essentially a nuanced conversation about the Dance. The cost/benefit to some people will be different than the cost/benefit to others. Eventually, there will need to be some strategy that will take into account three questions... 

What do you do for a living? How much social interaction does it take? Are you a yard person (less interaction) or an Uber driver (lots of interaction)? Could it be modified to add distance? Do you need to interact with only young healthy people or older and high-risk people? Is your job essential to keeping our society running, or is it a role that can be sacrificed temporarily until we get this curve under control? (btw - thank you both to the people providing the essential service and to those who have sacrificed their position for the time being)

How badly do you need to do your job? Do you have no savings? Are you or those you support one month away from not having a home or food?  

How bad is it if I get Covid? How old are you? Do you have a comorbid condition (diabetes, heart disease, heart failure, lung disease, immunocompromised)? Or, is someone that relies on you that is older or otherwise high-risk? 

• Example 1- If you are the only caregiver to an 80+ yr old parent and you're retired or work from home, then your cost/benefit ratio would be heavily skewed to maximizing your physical distancing (The last thing you want to do is to give Corona to your eighty-year-old parent when you can maintain your livelihood and care for you both with very little social interaction). 
• Example 2 - If you are a 25-year old with no savings, you can't make a living at home, you never interact with anyone over 60 yrs of age or with compromised conditions, and you have a job that is pretty isolated, then you will likely be able to err toward relaxing your physical distancing earlier.

What is the real problem with the lack of tests? 

Yes, there is a huge problem with the lack of tests. However, it is not going to change the type of care you will individually receive by a doctor. As best we can tell, the tests are only 70% accurate. So, a person needs 2-3 negative tests before they would be deemed "Corona free." The people I saw with cold-like or flu-like symptoms today got the presumptive diagnosis of Covid-19 and were told to self-isolate and come back if they got worse (particularly if they got short of breath). 

To a doctor sick is sick. Here is what I mean. Even if we had a 100% accurate, instantaneous, and limitless supply of tests, as a doctor, I would still send you home if you are well, and I would admit you to the hospital if you were sick - regardless of your test results. (I know for you physicians out there you are saying but wait... I could use it to risk stratify blah blah. I'm trying to make a point for the non-medical. The test does not cure you or treat the actual disease). 

The lack of current testing is bad because we don't know how bad the problem really is or where it is really located. Without this information, it is nearly impossible to create a plan that will be effective across an entire population of people. It's also a little harder to figure out which healthcare providers should stay in the game and which should sit on the sidelines. Certainly, if we could test every single person instantaneously with a 100% accurate test, this ordeal would be over in a few weeks. We would know exactly who needs to be isolated and who among us can stop physically distancing, and the virus would die out. Unfortunately, that is impossible.

What is the solution? 

Time. We need time. Physical distancing is the only way to make more time. It is a guarantee that true physical distancing will flatten the curve. There is no way the virus can magically jump from person to person. Simply put, the virus needs humans to interact in some way. The better and faster we distance ourselves from one another, the quicker we will affect the curve. We will never actually eliminate the sicknesses, but we only need to flatten the curve below the capacity of the healthcare system. Once we do this, then the cost-benefit ratio of flattening the curve changes significantly and then how flat should we try to get it is a really complicated question that I would love to watch really smart people debate.  

On the one hand, if we go too far, we will certainly experience too much of the negative economical and psychological consequences of distancing. However, if we don't go far enough, there will definitely be too much unnecessary suffering from people not getting the treatment they need because of an overloaded system. 

One thing is for certain, the flatter the curve the more time we have and...

• time will also allow us to learn what are the high-value distancing restrictions that provide the most benefit vs. the low-value ones that may be overkill (This is the proverbial "Dance.")
• time will let us increase our healthcare capacity. It will allow us to get the ventilators, the make-shift hospitals, and the safety equipment to the right places.  
• time will let us figure out if there is a drug combo that works. 
• time will let us create a vaccine. 

I don't know when we let off the Hammer. I know this it's not fully down yet in most places. My gut feeling says once it is the Hammer is down for weeks not months.  

In the meantime, all I'm asking is that each of you to stop and think.

• Think - how important is the physical interaction you want to go do and how much damage can it do? Is there an alternative? 
• Think - how important is isolation for you and how much benefit is gained by it?
• Think - how will by decisions affect both me and those around me? 

A few clarifying questions. 

Ok, Greg, I get it with the Hammer phase. But has the Hammer started yet? What does it look like? 

It has started in some places (New York, San Francisco, and Dallas, for instance). So, some places are in it and some aren't. Also, a number of people in places that aren't officially under the Hammer are voluntarily acting like we are under the Hammer by staying at home (Thank you very much!!). The more places in our country that go under the Hammer, the more effective this phase will be because there won't be cross-contamination (and also the sooner we will get out from under the Hammer altogether). 

What do you think the Hammer Phase will look like?

I predict the maximum Hammer that our country will tolerate is these "shelter in place" orders that are being issued State and City-wide. As I write this email, Harris County (Houston TX) just announced theirs. Also, we must realize that every area will have a slightly different curve because this pandemic hit different places at slightly different times. 

I imagine Shelter in Place orders will need to be enacted in all populated places. >10k people? >100k? people? I don't know, but the size of the area that will require the hammer will be a smaller number, not a larger one. It will have to do with each region's number of cases and their overall healthcare resources and capabilities. It is significantly more than one-third of our country, which is approximately where we stand today (It seems dangerous to be thinking about lifting the Hammer before it is even down yet). If you forced me to give a guess, my gut says maybe that 80% - 95% of our population will require this Hammer phase?? I really don't know, but I do know that it is a larger percentage. I am not an expert here -- just explaining the concept. 

Austin will just be starting the Hammer here tonight btw. Yeah, Austin!

Oh, jeez, so how long again? 

Remember in one of my first emails when I mentioned there would be 12 days of exponential growth after a lockdown? The China-style or Italian-style hammer has to be down at least 12 days before we will see if it is working (if it is not working, that means it needs to be stricter). It has to do with the incubation period of the virus (2-14 days). If the incubation period was 2-14 hours, we would see the effect of the lockdown much more quickly.  

The 12-days lockdown period came from the data in China, and Italy is following suit. Italy went on lockdown on March 9th. Do you want to guess which day they started to see a downward trend in their daily increase? March 9 + 12 days = March 21... 

I hope this is good data and not simply an anomaly from the lack of testing capacity, but either way, we should all be hoping that their trend continues because it gives us at least two hopeful data sets. Basically, we have to get control of the curve, and then we can work to bring it down below the current capacity of our healthcare system. Simply put, it will take a couple of weeks to actually see the outcome of what we have done. This is very, very hard to do, and it will be different for different parts of the country based on their viral burden and their healthcare capacity. The nuances are beyond my expertise, so I'm simply articulating the concept that we will need to be thinking through. 

Here's my message -- we seem very hesitant as a society to bring down the hammer fast. We are afraid of the hammer. Don't be afraid of the Hammer. It's a good Hammer. The longer we are afraid of putting it down the longer the Hammer will be around, and the longer it will take for us to get to the Dance. I know we all want to get to the Dance.  

Hey, Greg aren't you doing an amazing cool fun webinar today? 

In the haste of sending our email last night (which are the efforts of multiple people, by the way, thank you Jeff and Adrienne), I forgot to mention we are doing a fun webinar today that I think you will love. Its quiz time (https://info.kainexus.com/continuous-improvement/webinar/covid-19-quiz-show/signup)! We will be hosting a live interactive quiz with real-time questions. It will be a competition! Do you think you can win? It's cool, fun, and all you need is a phone to play along.  

Note: You can view a recording via that link, above.

I'll let you figure out how many questions there will be ;). 

Stay emotionally connected and physically distant,

Greg

PS For more context on what we are doing here, there is a list of all the prior emails here (https://www.kainexus.com/updates-from-greg-jacobson-covid-19).