I figured it would be very difficult to write another blog article (which I do fairly infrequently now) without referencing the current COVID-19 pandemic, or what has become colloquially known as, “these challenging times” (good lord I’m getting tired of hearing that phrase – regardless of how accurate it may be).
Anyways, as a geriatric psychologist and one who has worked for a number of years in a medical setting (skilled nursing) for a number of years, I figure I have a unique perspective to speak about all of this.
COVID and Nursing Homes – We are Ground Zero
I must say it’s been rather interesting working in the nursing home field right now. Typically, skilled nursing very much functions as a forgotten corner of the medical landscape, the armpit, the red-headed-stepchild. To put it cynically, in an almost brutal fashion – nursing homes are the place that old people “go to die,” it’s where people go when families have become unable to care for a loved one, or worse, where they are “dumped off.” Ironically, while skilled nursing is arguably one of the most extensively regulated sectors of the US economy, many nursing homes have been very difficult places for older people to live, to put it mildly, with high costs and substandard care being often the norm. Generally speaking, nursing homes are, as I spoke of before, generally forgotten places. People don’t really think about older adults when they’re in nursing homes – they can just be tucked away there and forgotten.
Not anymore! The COVID-19 crisis has made everyone wake up, and wake up big time. One reason for this is the following chart, which I’ve referenced before:
While the above link references data from COVID deaths in China, suffice it to say, the data hasn’t played out much different in other well-known hotspots like Italy, or the State of New York. COVID-19, while a very serious illness at most any age (although arguably a non-issue for those under 10 years old), has been called an “almost perfect killing machine” for older adults. Moreover, of the over 90,000 COVID-19 deaths that have been counted in the US thus far as of this writing, apparently somewhere in the neighborhood of 1/3 of them have been occurring with US nursing home residents or workers.
So, no matter one’s personal perspective about how deadly or how not, or how at-risk you are or are not personally, from the COVID-19 pandemic, or no matter how strongly you may feel about so-called “stay at home” or “lockdown” orders, there’s no question – my population, my nursing home patients – they are the most vulnerable and need maximum protection from this, no matter what.
Now, on to the rest of us.
COVID – My Initial Response: LOCK IT DOWN!
Initially, when I saw COVID explode onto the scene, it reminded me of my initial response to 9/11, in the first couple weeks after seeing the twin towers fall. It was a response borne entirely of emotion, in this case, it was borne of a mixture of fear, largely replaced by anger. “Bomb ‘em all!” I said (referring to the terrorists that attacked us), and I largely didn’t care about anything other than making sure that wherever the 9/11 terrorists hid (Afghanistan), we needed to support the government in making sure they did everything in their power to bomb their butts back to the proverbial stone age.
Of course, after Afghanistan, the government then turned it’s attention to Iraq, my skeptical nature kicked in, my emotions calmed down, and we know the rest of the story. The “war on terror” remains, with the attendant issues with civil liberties / surveillance at home, and an entrenched and increased military presence abroad that nags us today. We arguably have grossly overreacted and have paid the price for it, and continue to pay the price for it.
Back in late February and early March, I had a similar response when the national panic about COVID set in, and the escalating lockdowns and shelter-in-place orders began coming out from politicians’ offices both on the local and most notably, state level. Initially, I was frightened, scared, and frankly – supportive. Lock it all down!
The Media Base Case for ‘Lock it Down’
Like everyone else, I encountered several influential articles when this all started to happen very quickly.
The first I recall was from the Washington Post, which featured a series of interactive infographics where you could essentially model the spread of disease across different types of social distancing approaches. The article made a strong case (via simulation) – that mass social distancing, rather than mitigation was the way to go (and doing nothing is obviously madness).
Then there’s this one – “The Hammer and the Dance” – published by Tomas Pueyo which I think everyone ate up simply because he was so eloquent in how he framed the ideas of enforced social distancing (e.g., “shelter in place” orders, or more straightforwardly, what people have been calling “lockdowns.”) Similar to the Washington Post article – it made a strong rhetorical and visual case (the Pueyo piece was packed with graphs) for government-enforced social distancing, at least until treatments or cures can be found, but at least so we can be assured that the healthcare system would not be overwhelmed by COVID-19 cases, so-called “flattening of the curve.”
One of the last major online sources that I personally see as being hugely influential in the beginning was the following online tool from The Institute for Health Metrics and Evaluation (IHME) – located at https://covid19.healthdata.org/united-states-of-america.
Regarding the IMHE website – there’s no question about it, it’s a pretty darn cool thing they’ve created. What it does is take the known relevant COVID-19 inputs, which includes confirmed infections, confirmed deaths, hospitalizations, and ventilator usage, and then using the tried and true tool of non-linear regression, they essentially, well, predict the future.
One could argue that the IMHE’s models may have issues with the old “garbage in, garbage out” problem. In the United States, issues with availability of COVID-19 testing have been an enormous problem, and have made accurately determining the Case Fatality Ratio, or CFR – which is calculated via the number of infected people divided by the number of confirmed deaths – extremely problematic. In other words, if you don’t know the proper inputs (e.g., the number of people who actually have the disease), you’re never going to figure out how deadly the actual disease is, or how fast it spreads – you know, useful stuff that epidemiologists need to know!
That being said, because testing capacity in the USA was so sparse in the ‘early days,’ (back in early March), there’s really no other way to put it – statistical modeling of disease outbreak was all we had. And early on, another highly influential group from the Imperial College of London published this, which made the case that the United States was staring down the barrel of 2.2 million deaths if we collectively “did nothing” in the face of the COVID-19 pandemic.
This scared the heck out of everyone, and so began our march into the new “challenging times” we find ourselves living in.
COVID-19 as seen by a Geropsychologist
I’m not unfamiliar with the whole problem of viral pandemics.
In fact, about 12-15 years ago I had a 3-4 year obsession with influenza pandemics (sparked by worries about H5N1 mutating into a pandemic flu), and read everything I could get my hands on about pandemics and how to survive them, including John M. Barry’s masterpiece of nonfiction, “The Great Influenza.”
As everyone knows about me, I work in a nursing home, and in fact, have worked in long term care on and off for the past 15 years. Infection control and grappling with periodic localized epidemics in our workplace is a common feature of being in long-term care, if not facility-based healthcare writ large.
Moreover, I’m more than aware that disease spread is a social phenomenon, driven by the fact that humans are essentially pack animals and are driven to congregate with each other, often in close contact – something that viruses depend on when it comes to engineering their nefarious activities.
Finally, I’m more than familiar with multivariate statistics and modelling, as I’ve used them in my own scholarly work, and frankly need to evaluate them in the work I do as a clinical scientist.
That being said, I’m not an epidemiologist, physician, or disease specialist, and I am very much poorly able to comment on things such as, for example, the true pathogenicity of COVID-19 in all its various forms / strains that may be circulating the globe right now. Is a vaccine possible in the future? Can people become immune after being infected with COVID-19? Is “herd immunity” possible absent a vaccine? I really don’t know – not my area and I’m not going to pretend I know one way or another, although I’m watching this all very closely.
Social distancing =/= Lockdown!
Where did the idea of “social distancing” begin?
Before we get into that, we should probably get an idea firmly into our heads from the very start. First thing is that social distancing as a way of slowing or preventing spread of a communicable disease is *not* the same thing as government-enforced shutdowns of so-called “nonessential businesses,” or mandatory mask laws, et cetera.
Second, social distancing is not a way of preventing people from getting infected with a virus – instead, it’s a way of delaying infection, so as to prevent a healthcare system from becoming overburdened with the critically ill.
And it has precedent – with the most famous case being the differences in approaches taken between Philadelphia and St Louis in 1918 as the so-called Spanish Flu was beginning to ravage the United States (there’s a number of accounts of this, but I’m taking this from Hatchett, Mecher, and Lipsich’s 2007 research article from the Proceedings of the National Academy of Sciences of the United States of America).
In the case of Philadelphia, they largely eschewed social distancing and government policy reflected this with no bans on public gatherings and no school closures or other enforcement of social distancing measures. St. Louis, however, did the opposite and aggressively enforced a broad series of measures like closures, bans on large groups, etc. This apparently yielded results, with Philadelphia being much more adversely affected with a much more pronounced death toll than St. Louis – with a death rate of 257/100,000 versus Philadelphia’s 31/100,000.
However, Hatchett et al. notes, there are a couple of caveats – first, these non-pharmaceutical social distancing measures “were limited to the time they remained in effect.” This makes sense – no one would assume that social distancing could ever eliminate a virus, instead, it simply slows it down. Second, Hatchett et al. notes that social distancing may in fact kick the can down the road to a certain degree, with “cities that had low peaks…” (produced by aggressive social distancing) “…during the first wave were at greater risk of a large second wave.”
Why would this be?
COVID-19 and Concerns about a Second Wave
Remember, I’m a psychologist by trade, and a social scientist by training. While I don’t know much more than what I read (albeit obsessively) as a more-or-less layperson when it comes to viral pandemics, I do know that for viral pandemics, a so-called “second wave” of illness is all but guaranteed. What that means is – after this initial peak in infections and deaths is over, we’ll get a pause, and then likely restart somewhere in the fall or winter. This happened in 1918 and resulted in a far more severely pathogenic and deadly illness in it’s second wave than it’s first.
Why do second waves happen? There’s a lot of theories, and many of them depend pretty intimately on an understanding of how viruses tend to mutate and spread, the effects of seasonality (e.g., there’s been a lot of talk about why viruses tend to be less problematic in summer – particularly when it’s warm and humid), and other factors that are out of my scope. But I think we can plan for it.
Here’s my concern. In the United States, due to us being in the “fog of war” (due to an absence of testing capacity – we didn’t really know how severe and how broad-based the lethality of COVID-19 really was), we imposed mass lockdowns on most of the country that have thrown millions out of work and have likely imposed significantly elevated burdens on the poor, those who work low-level retail jobs (e.g., those who cannot take the upper-class privilege of telecommuting), and those who live in domestic abuse situations, or those with mental health issues. Suicide, alcohol abuse, and opioid deaths will most definitely be on the rise as a result of these lockdowns. This isn’t an argument necessarily against these “shelter in place” and lockdown orders – because particularly if the risk of unmitigated spread is high enough, then these costs are perhaps worth it.
However, this *does* note that our current, sweeping, “extreme social distancing” policies typified by these government lockdowns are likely in the process of resulting in some extreme stress on society at large that is likely very difficult to successfully sustain over the long term – and we know that COVID-19 will likely be with us for a long time.
What I worry is that we will not be able to sustain our current path, and that many or most localities will, either because governments will be pressured into relaxing social distancing, or because individuals will begin to skirt these laws and restrictions individually and en masse, we will see COVID-19 roar back, stronger than ever, and we won’t be able to muster the discipline needed to beat it back a second time. As Bjorn Lomborg says in the following excellent Forbes article on April 9th:
“These policies cannot realistically be sustained for many months, let alone years. Already now, cell phone tracking shows that 40 percent of Italians still move around, despite curfews and lockdowns. In France, ‘virusrebels’ are defying bans and young Germans hold ‘corona parties’ while coughing at older people.
“As weeks of shutdown turn into months, this will get much worse. With many more people at home, this will likely lead to higher levels of domestic violence and substance abuse. As schools stay closed, the skills of the next generation erode. One study shows closing schools for just 13 weeks could initially cost the economy 8.1 percent of GDP. As more become unemployed and the economy plunges, we will all be able to afford much less, also leading to lower-quality health care for everyone. Politically, the outcome could be dire — the previous long-term recessions in the 1920s and 1930s didn’t end well.”
Sustainable, Smart Mitigation – The Swedish Approach
I’ve been growing more and more fascinated with the Swedish government’s approach to the COVID pandemic. Initially, like everyone else, I heard that the Swedish government and the UK were both planning on essentially “going it alone” and going for a targeted mitigation approach (with extreme social distancing enforced only for geriatric populations and those living in nursing homes), and from what I had heard and read initially, I thought this was complete and utter madness.
Now, I’m not so sure. Although the UK government initially was going to join Sweden, now it’s only Sweden who has basically spurned what the rest of the industrialized world (and most of the rest of the world has done) – instead of a mass, “lock it all down” policy, Sweden has chosen instead to keep schools and businesses largely open. Restaurants can still serve customers, but for sit-down service only. You can gather in groups, but no larger than groups of 50. Nursing homes, like everywhere else, however, are strictly locked down – and this is because of the recognition that older adults are the highest-risk groups in this pandemic, and should be treated as such.
For some articles on the Swedish approach:
World Health Organization lauds lockdown-ignoring Sweden as a ‘model’ for countries going forward:
Sweden resisted a lockdown, and its capital Stockholm is expected to reach ‘herd immunity’ in weeks
‘Life has to go on’: How Sweden has faced the coronavirus without a lockdown
Finally, for a really nice interview by those libertarian types at the American Institute for Economic Research, where they interview basically the brainchild of the Swedish approach to COVID mitigation – Professor Johan Giesecke, now head of the Health Emergencies Programme of the World Health Organization.
I like the Swedish approach. First of all, it recognizes that pandemic disease mitigation, particularly given the fact that we do not have a vaccine or effective treatment on the horizon, is a marathon, not a sprint. Second, it recognizes that those populations at highest risk (e.g., in this case, the old, and infirm – basically the folks that live at my nursing home!) are the ones that need protection with strictly enforced, extreme social distancing. For the rest of us, given what we have known about COVID, it’s really much smarter for us to continue to go about our lives and feed our families, take care of each other, and contribute to society in the ways we are most capable – because largely locking down the economy has severe costs of it’s own.
Finally, it recognizes that if COVID-19 shifts and mutates into something far more pathogenic and sinister (which it certainly may do, if the worst-case scenario for a second wave of illness comes to fruition) we have the resources to actually do it right – instead of exhausting ourselves with disproportionately extreme, one-size-fits-all lockdown approaches that we tried to implement on an interminable basis, with no clear endpoint in sight.
As it turns out, “doing nothing” means exactly that – the Imperial College’s article makes it clear that they aren’t saying “doing nothing” as in no lockdowns, or no government-mandated social distancing, or even mitigation – they were literally saying 2.2 million COVID-19 deaths would be the result if no one in the US changed their behavior at all. Which, in retrospect, seems like a pretty ridiculous assumption to even be talking about.
Hard to talk about conclusions at this point. We’re not even into the second wave yet, and now we’re hearing about temporary hospitals being shut down in the US, and states going back to business. We’re not even done with the first lap, and yet we’re acting like the marathon is half over.
We’ll see how this goes….