A More Balanced Strategy for Covid-19

By Paul E. Lemanski, MD, MS, FACP

The Covid-19 pandemic in the United States was projected – in a worst-case scenario – to infect as many as 214 million and kill as many as 1.7 million. By June 15th, approximately 120,000 have died. This apparent success (it ain’t over till it’s over) is in part a result of a massive effort on the part of state and federal governments to reduce transmission of the virus via masking, social distancing, hand washing, quarantine of identified cases, as well as the closing of non-essential business/commerce, and keeping folks at home – and thus not congregating. While apparently meeting initial success, the strategy has had other deleterious effects on the economy and healthcare delivery that also pose a significant threat to the health of our population. A more balanced approach is needed.

The strategy employed was intended to “flatten the curve” or slow the spread of the virus in the population so as not to overwhelm the capacity of the healthcare system to care for the seriously ill; to allow a ramp up in production of personal protective equipment; to allow time to develop antiviral medications; and to allow time for the development and administration of a vaccine. The strategy was not intended to stop transmission. Moreover, the strategy has created new and significant health threats.

For example, hospitals have noted that the usual number of patients with heart attack and strokes have not been showing up at emergency rooms for treatment, ostensibly out of fear of contracting the Covid. Moreover, those that do call an ambulance are calling later with a resultant increase in out-of-hospital cardiac arrest. Needed vaccinations are being put off, needed cancer screenings are being put off, and even needed cancer treatments are being delayed, out of fear of Covid. The economic distress of job loss has increased domestic abuse and suicide rates. Moreover, loss of jobs may mean loss of health insurance, inability to meet co-pays, and reduced access to care – with serious health outcome implications.

Most recently, an increase in cases across the Sunbelt has raised the possibility of further lock downs and stay-at-home orders. The strategy of lock downs and stay-at-home orders, however, is draconian and creates, as noted above, other economically precipitated detrimental health outcomes. However, as our knowledge of the virus – its transmission and most vulnerable targets – has increased, a more balanced approach may be better. As first suggested in a March 20, 2020 article in The New York Times, titled “Is our Fight Against Coronavirus Worse Than the Disease?,” David Katz, MD argues that a more risk-stratified approach, saving lock downs, extensive testing, and stay-at-home orders for those older and sicker individuals at highest risk, may allow those at lower levels of risk to resume their jobs “safely.” I would emphasize that safely reopening requires even for those at lower risk a continuation in some form of those mitigating strategies we know work – masking, social distancing, handwashing and targeted quarantine.

Until a vaccine is available, the lifestyle-based mitigation strategies mentioned above, are the only thing standing in the way of hundreds of thousands of additional deaths. But these strategies must be used in order that the rate of new infections remains low, allowing the healthcare system to respond appropriately, and not be overwhelmed. For example, Taiwan has some of the lowest transmission and case rates in the world. Part of this may be traced to early closure to visitors from the mainland, but equally important has been the widespread use of masks after the SARS scare in 2003, in which mask wearing proved its efficacy to the general population – and consequently has been accepted more readily as a social responsibility during Covid-19. But even in Taiwan, the social acceptability of masking is backed up by economic consequences: failure to wear a mask in public results in a $500 fine.

While such financial penalties may not be politically acceptable in the United States, certainly the strongly encouraged use of mitigation strategies known to work – universal masking, social distancing, hand washing, and quarantine of identified cases – is less draconian, less detrimental to the economy, less likely to result in other negative health outcomes, and more American than stay-at-home orders for the bulk of the population at lower risk.

It would make sense to balance this approach, with more stringent and restrictive targeted interventions only for those at higher risk, and thus for the majority of the population to achieve some degree of normalcy. Nevertheless, these lifestyle-based mitigation strategies will work only if we use them. Let’s resolve to do so!

Paul E. Lemanski, MD, MS, FACP is a board-certified internist practicing internal medicine and lifestyle medicine in Albany (centerforpreventivemedicine.com). Paul has a master’s degree in human nutrition, he’s an assistant clinical professor of medicine at Albany Medical College, and a fellow of the American College of Physicians.