As we wrestle with how to most effectively prevent and mitigate Covid-19, it is important to clearly explain risk and prevent unnecessary fear. As Dr. Fauci says, we must take this very seriously but not panic. An evidence-based and transparent debate must underpin decisions, obviously taking into consideration the massive consequences of financial collapse and lost income resulting from a prolonged economic shutdown.
When the first AIDS cases were reported in 1981, I was living in the San Francisco Bay area. As the waves of death mounted, I volunteered at a hospice and later conducted epidemiological research at the University of California. Although there are huge differences between the two viruses and resulting pandemics, I’m having déjà vu: from the devastating number of deaths as well as the atmosphere of confusion, fear and often panic.
With AIDS political mistakes were made, commencing with President Reagan’s appalling neglect, followed by acrimonious ideological warfare. In hindsight, health authorities also made some decisions – especially under the intense pressure of needing to act immediately – which led to sub-optimal and ultimately costly outcomes.1,2 Policies often become hard-wired over time and difficult to walk back, even after new evidence appeared. Well-meaning messages such as “Always use a condom with anyone, or die” inadvertently created other problems, and greater openness to scientifically innovative approaches could have saved lives.1-3 In subsequent years, as funding for research and treatment eventually began pouring in, a kind of “AIDS exceptionalism” also became imbedded.4
During the first years of the AIDS response, much was unknown regarding the causes and main modes of transmission. Yet even after the HIV virus was identified in 1983 and the basic science became clearer, a great deal of uncertainty, persecution of marginalized groups, and terror persisted. Rumors proliferated that anything from mosquitoes to contaminated condoms to sharing toothbrushes were spreading the virus. In the 1990s, after Magic Johnson tested positive, counseling centers became overrun by “worried well.”1,5 College students flooded in, petrified from having engaged in deep kissing or intimate touching, diverting attention from those actually at significant risk of infection.
With Covid-19, much remains unclear, but some basic facts are known and more emerge daily. Yet there’s a pervasive sense of confusion and anxiety. Although fear is understandable under the circumstances and can help motivate behavior change,1,6 irrational panic results in unintended consequences.7,8 Furthermore, we are being presented (i.e., by politicians and the media) with a false dichotomy, of having to choose between recklessly abandoning mitigation efforts in order to reopen the economy versus strictly continuing the present lockdown measures. In Puerto Rico, where a semi-militaristic shutdown was implemented in mid-March after the first death here (of an Italian cruise ship passenger), many people won’t drive to pick up groceries, terrified that infection is unavoidable. (I’ve been interrogated by police for walking outside; even in the world’s hardest-hit country, Italy, a single parent and child are allowed outdoors for exercise.) Numerous restaurants, especially Chinese-owned, have closed after losing take-out customers, and when food delivery services are overwhelmed some elderly and sick persons cannot obtain essential supplies.
As elsewhere, young people and others with asthma are extremely anxious, prompting frequent shortages of inhalers and other critical supplies. The CDC website lists asthma sufferers near the top of those at risk of severe Covid-19 outcomes, while the Allergy and Asthma Foundation notes <a href="https://community.aafa.org/blog/please-don-t-stop-your-asthma-medicines-an-editorial-from-dr-mitchell-grayson-on-coronavirus-covid-19">there’s little evidence yet of an association, </a>which has so far only been investigated in one study (from China, finding no link9), although cautioning that asthma has worsened with other coronavirus strains. Considering the many younger people – undoubtedly including many asthma sufferers – who have already been infected, logically a much higher proportion of severe outcomes should be reported in younger populations, if asthma alone were a significant risk factor. Emerging data appears to confirm the absence of an association,10 yet it remains unclear whether the CDC will correct its website information.
What is increasingly clear, based on evidence from Italy, China and the US,11,12 is that preexisting serious diseases, and especially multiple illnesses, are greatly associated with severe outcomes and deaths from Covid-19. It may be that advanced age by itself is less of an important risk factor than assumed; the elderly (especially male smokers) are more likely to have such underlying conditions. Certainly, this data underscores the ongoing importance of aggressively addressing chronic diseases, including prevention of underlying conditions such as obesity.13,14
Regarding Covid-19 prevention, it’s imperative for experts to agree on what are likely the main correlates of infection and to carefully determine which are accordingly the most effective – and realistically achievable – ways to reduce transmission. It seems probable that, as with influenza, most infections occur from close exposure to someone coughing or, given the many asymptomatic carriers, from other direct and relatively prolonged contact. Senior WHO advisor David Heymann believes nearly all transmission in Wuhan occurred between family members and co-workers, and emerging data suggests that severity of outcomes is associated with initial exposure level.15,16 As happened eventually with HIV, experts could assist the public to distinguish between those behaviors and situations posing the highest risk for infection versus those of likely lower risk (such as the virus lingering on hard surfaces for extended periods) versus very unlikely or impossible modes. Such guidance, if widely disseminated, would help reduce unnecessary time and attention spent addressing low-risk concerns, like healthy people being worried (even if practicing precautions) to leave home for necessary activities.
One example of inconsistent public health messaging is that European and Asian authorities and the WHO have recommended physical distancing, based on data that droplets containing the virus have been identified almost a meter away from coughing individuals. In the US, meanwhile, “one meter” translated into “5 feet” and subsequently became “over 6 feet.” While perhaps not the main priority, it would nevertheless be useful for the CDC and other experts to determine whether such abundance-of-caution guidance is worth maintaining the discrepancy from international standards, or perhaps is not scientifically warranted and inadvertently feeding excessive concern. It’s certainly more practical to maintain about 3 feet distance than 6 feet in many situations, such as grocery shopping or when walking with a companion (where outdoor exercise is still permitted, which some health departments continue to encourage17). And critically, once the economy begins to reopen it would be more complicated for some businesses to strictly adhere to a 6-foot rule.
Indeed, it is quite likely that a more “surgical” (more carefully contemplated, evidence-based) approach would be as – or at least nearly as – efficacious as the more extreme isolation strategies currently implemented. Singapore for example had achieved an effective response, without closing schools.18 While most experts concur that stay-in-place measures are still needed to temporarily flatten the curve, some propose a Phase 2 alternative to attempting to eliminate all new infections, based instead on a herd immunity approach of allowing younger and healthier people to gradually return to work and school.18-22 While many could eventually become infected, most would suffer relatively mild to moderate symptoms and, after self-quarantining, would effectively be “vaccinated” (assuming re-infection is rare, which is probable but remains unconfirmed23,24) and therefore presumably no longer able to spread infection. Such an approach would be strongly enhanced by large-scale antibody testing to identify previous infection, as Germany, the UK and China are planning.25,26Crucially, we must determine how best to isolate or otherwise protect the most vulnerable from infection – no easy task.
While far from ideal, something along those lines may emerge as the least-terrible realistic longer-term alternative, until a vaccine is available. Interest in such strategies is intensified by the potential for a resurgence of infections once containment measures are eased. We need to assess outcomes in places like Sweden that attempt similar approaches,27 not because the rate of infections or deaths would be lower but – if outcomes are no worse than elsewhere – this suggests that similar results can be achieved at substantially less economic-societal cost. It may also be noteworthy that in the five US states which have not enforced stricter isolation measures28 (and in the seven states that until recently had also not done so), so far there does not appear to have occurred any measurable increase in new cases, compared to neighboring and similarly rural states.
In any case, an evidence-based and transparent debate should underpin decisions, obviously taking into consideration the massive consequences of financial collapse and lost income resulting from a prolonged economic shutdown,17,20 as most painfully experienced among the poor and most dangerously in the poorest countries29 (including unintended consequences of potentially harrowing proportions30). We must also weigh the likely increases in domestic violence31-33and other physical and mental health implications (for chronic disease and depression,7,8,16 possibly suicide, OCD,34 etc.) of remaining inside often-cramped living quarters for an extended duration.
Lastly, perhaps it’s not premature to address the most vital longer-term question, of how to prevent future – and conceivably even more horrific – pandemics. This virus may have originated partly from pangolins, the world’s most trafficked animal.35 Up to a million pangolins have been smuggled into China over the past decade from Southeast Asia and Africa, where many are kept in cages next to other animals in traditional medicine and exotic pet shops.36 The time to forcefully ban such practices may finally be imminent.
Daniel T. Halperin, PhD, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
Notes
<ol>
<li>C. Timberg, D. Halperin, Tinderbox: How the West Sparked the AIDS Epidemic and How the World Can Finally Overcome It (Penguin Books, 2012). <a href="http://tinderboxbook.com/#_blank">tinderboxbook.com</a></li>
<li>H. Epstein, The Invisible Cure: Why We Are Losing the Fight against AIDS in Africa (Farrar, Straus, &amp; Giroux, 2007).</li>
<li>M. Potts, D. T. Halperin, D. Kirby, A. Swidler, J. D. Klausner, E. Marseille, N. Hearst, R. G. Wamai, J. G. Kahn, J. Walsh, Reassessing HIV prevention. Science, 320, 749-750 (2008).</li>
<li>D. Halperin, Putting a plague in perspective. NY Times, January 1, 2008, p. A19; www.nytimes.com/2008/01/01/opinion/01halperin.html</li>
<li>K. Roiphe, Last Night in Paradise: Sex and Morals at the Century’s End (Little, Brown &amp; Co, 1997).</li>
<li>K. Witte, M. Allen, A meta-analysis of fear appeals: implications for effective public health campaigns. Health Education Behavior, 27, 608-632 (2000).</li>
<li><a href="https://www.nytimes.com/by/bret-stephens">B. Stephens</a>, It’s dangerous to be ruled by fear: the reaction to the pandemic should not be allowed to become as dangerous as the disease itself. NY Times, March 20, 2020.</li>
<li>A. Ripley, Five ways to conquer your Covid-19 fears. Wash Post, April 6, 2020.</li>
<li>J. J. <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Zhang%20JJ%5BAuthor%5D&amp;cauthor=true&amp;cauthor_uid=32077115">Zhang</a>, X. <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Dong%20X%5BAuthor%5D&amp;cauthor=true&amp;cauthor_uid=32077115">Dong</a>, Y. Y. <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Cao%20YY%5BAuthor%5D&amp;cauthor=true&amp;cauthor_uid=32077115">Cao</a>, Y. D. <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Yuan%20YD%5BAuthor%5D&amp;cauthor=true&amp;cauthor_uid=32077115">Yuan</a>, Y. B. <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Yang%20YB%5BAuthor%5D&amp;cauthor=true&amp;cauthor_uid=32077115">Yang</a>, Y. Q. <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Yan%20YQ%5BAuthor%5D&amp;cauthor=true&amp;cauthor_uid=32077115">Yan</a>, C. A. <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Akdis%20CA%5BAuthor%5D&amp;cauthor=true&amp;cauthor_uid=32077115">Akdis</a>, Y. D. Gao, Clinical characteristics of 140 patients infected with SARS-CoV-2 in Wuhan, China. <a href="https://www.ncbi.nlm.nih.gov/pubmed/32077115">Allergy</a>doi:10.1111/all.14238 (2020).</li>
<li>D. Hakim, Asthma is absent among top Covid-19 risk factors, early data shows. New York Times, April 16, 2020.</li>
<li><a href="https://www.bloomberg.com/authors/AGx9I9uf5QM/tommaso-ebhardt">T. Ebhardt</a>, C.<a href="https://www.bloomberg.com/authors/ADVWBNrFZmY/chiara-remondini"> Remondini</a>, M. <a href="https://www.bloomberg.com/authors/AFNdMg9QDak/marco-bertacche">Bertacche</a>, 99% of those who died from virus had other illness, Italy says. Bloomberg News, March 18, 2020.</li>
<li>CDC DATA (&amp; CHINESE DATA?)</li>
<li>E. A. Finkelstein, J. G. Trogdon, J. W. Cohen, W. Dietz. Annual medical spending attributable to obesity: payer-and service-specific estimates. Health Affairs; 28, 822-831 (2009).</li>
<li>Halperin, D, Puerto Rico’s man-made disasters will kill more people than natural catastrophes. Miami Herald, January 20, 2020. https://www.miamiherald.com/opinion/op-ed/article239463738.html</li>
<li>C. Heneghan, J. Brassey, T. Jefferson, SARS-CoV-2 viral load and the severity of COVID-19. Oxford COVID-19 Evidence Service Team, Centre for Evidence-Based Medicine, University of Oxford, March 26, 2020.</li>
<li>G. Kolata, Why are some people so much more infectious than others?: Solving the mystery of “superspreaders” could help control the coronavirus pandemic. NY Times, April 12, 2020.</li>
<li>G. Popkin, Don’t cancel the outdoors; we need it to stay sane. The health consequences of cutting ourselves off from nature could be catastrophic. Wash Post, March 20, 2020.</li>
<li>M. T. Osterholm, M. Olshaker, Facing covid-19 reality: a national lockdown is no cure. Wash Post, March 21, 2020.</li>
<li>J. P. Ioannidis, A fiasco in the making? As the coronavirus pandemic takes hold, we are making decisions without reliable data. STATNews, March 17, 2020.</li>
<li>D. Katz, Is our fight against coronavirus worse than the disease? There may be more targeted ways to beat the pandemic. NY Times, March 20, 2020.</li>
<li>T. L. Friedman, A plan to get America back to work. NY Times, March 22, 2020.</li>
<li>G. Leung, Lockdown can’t last forever: here’s how to lift it. We need to hit and release the brakes on physical distancing, again and again, until we safely get to immunity. NY Times, April 6, 2020.</li>
<li><a href="https://www.newscientist.com/author/graham-lawton/">G. Lawton</a>, Can you catch the coronavirus twice? We don’t know yet. New Scientist, March 25, 2020.</li>
<li>L.Bao, W. Deng, H. Gao, C. Xiao, J. Liu, J. Xu, et al, Reinfection could not occur in SARS-CoV-2 infected rhesus macaques. BioRxiv doi.org/10.1101/2020.03.13.990226 (2020).</li>
<li>A. Bienkov, Germany could issue thousands of people coronavirus &#8216;immunity certificates&#8217; so they can leave the lockdown early. Business Insider, March 30, 2020.</li>
<li>A. Regalado, Blood tests show 14% of people are now immune to covid-19 in one town in Germany. MIT Technology Review, April 9, 2020.</li>
<li>T. Lister, S. Shukla, Sweden challenges Trump &#8212; and scientific mainstream &#8212; by refusing to lock down. CNN News, April 10, 2020.</li>
<li>J. Gershman, A guide to state coronavirus lockdowns. Wall St. J, April 14, 2020.</li>
<li><a href="https://www.nytimes.com/by/maria-abi-habib">M. Abi-Habib</a>, <a href="https://www.nytimes.com/by/sameer-yasir">S. Yasir</a>, India’s coronavirus lockdown leaves vast numbers stranded and hungry. NY Times, March 29, 2020.</li>
<li>L. Roberts, Polio, measles, other diseases set to surge as COVID-19 forces suspension of vaccination campaigns. Science, Apr. 9, 2020.</li>
<li>R. Zakaria, Domestic violence and coronavirus: hell behind closed doors, The Nation, April 2, 2020.</li>
<li>S. Neuman, Global lockdowns resulting in &#8216;horrifying surge&#8217; in domestic violence, U.N. warns. NPR News, April 6, 2020.</li>
<li>M. Godin. France to put domestic violence victims in hotels as numbers soar under coronavirus lockdown. Time, March 31, 2020.</li>
<li>D. Adam, The hellish side of handwashing: how coronavirus is affecting people with OCD. The Guardian, March 29, 2020.</li>
<li>Lam, T.T., Shum, M.H., Zhu, H. et al.Identifying SARS-CoV-2 related coronaviruses in Malayan pangolins. Nature(2020). https://doi.org/10.1038/s41586-020-2169-0</li>
<li>W. Yu, Coronavirus: Revenge of the pangolins? NY Times, March 5, 2020.</li>
</ol>
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Daniel T. Halperin

HALPERIN: As Past Pandemics Have Taught Us, Science Well Implemented Can Help Reduce Infections As Well As Irrational Fear