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To Re-Open Safely We Need a "Health Force" of Disease Detectives
In the long run such a workforce could help address the long-standing shortage of primary care in the United States—including community-based programming to assist families with preventive health, nutrition, exercise, chronic diseases and mental health needs.
May 13, 2020
Conservative governors are now openly at odds with epidemiologists as plans move ahead for more than half the states to loosen social distancing and permit many businesses to re-open this month despite none of them meeting White House Coronavirus Taskforce guidelines.
Unlike re-openings in China, Hong Kong and South Korea where new cases fell rapidly after aggressive containment efforts, the United States, with nearly 1.4 million cases and over 81,000 COVID-19 deaths (as of May 11), must follow a different model.
Many critics blame the Trump Administration's laggard scale-up of testing for the dilemma. But studies of past emerging disease epidemics have taught us that testing alone will not prevent new outbreaks. To re-open the economy we must undertake the most massive effort to trace and isolate new infections in history.
Ironically, the states moving most rapidly to restore commerce--eg. Georgia, Texas, and Florida--not only have regions with high case loads, but also inadequate public health workers to contain new outbreaks, according to a study by Politico. In the Midwest, despite high case loads per capita in Iowa and Nebraska, officials are jumping ahead of federal criteria calling for two weeks of falling cases before relaxing stay-at-home rules. Robert Redfield, director of the Centers for Disease Control and Prevention (CDC), warns that re-opening requires not only ramped up testing, but "very aggressive" contact tracing of new cases. Such disease tracking, together with testing, was critical to controlling spread of the virus in South Korea, New Zealand, Germany and China.
An April 27 letter released by former public health officials, including Andy Slavitt, who ran Medicare and Medicaid in the Obama administration, and Scott Gottlieb, a former Food and Drug Administration chief under President Trump, estimated 180,000 contact tracers are needed to re-open the economy. Tom Frieden, who directed the CDC from 2009 to 2017, extrapolated from experiences in Asia to estimate that up to 300,000 such workers may be needed across the country. At present local health departments and the CDC have only about 2,200 professional "disease detectives," although other health staff often assist during a contagious outbreak.
Until early May, federal officials and the media have tended to ignore contact tracing despite the critical role it has played in every infectious disease outbreak. The labor-intensive nature of the task is probably why. Our chronically underfunded, and now overwhelmed, public health departments have no capacity for such a massive scale up without significant new funding.
A recent NPR survey and follow-up report on 44 state health departments turned up a total count of 11,142 workers trained in contact tracing. As a point of contrast, at the height of China's viral crisis it took 9,000 contact tracers in Wuhan alone to contain the outbreak. Officials in state health departments surveyed described a variety of plans to expand capacity, some relying on volunteers, with the goal of scaling up to 66,197. Most will need federal aid for the new hires.
Unfortunately, there is no federal health workforce or emergency fund up to the task. The closest we have to a US rapid response team might be the Medical Reserve Corps (MRC), which matches over 175,000 volunteers with public health and medical assistance needs across the country. Thousands of MRC volunteers are now deployed in call centers or administering tests during the coronavirus crisis. Some may be trained as contact tracers in coming months.
We also entered into the COVID-19 crisis with a shortage of nurses and primary care doctors. The Chinese government sent 42,000 health workers to the Wuhan from other parts of the country. Despite the likelihood that many new hot spots will crop up here as we re-open, the United States lacks a coherent mobile medical corps of professionals who can be deployed rapidly. Given the perpetual shortages of physicians in US rural areas, another program that deserves to be scaled up is the underfunded "National Health Service Corps" which ties medical school loan forgiveness to commitments by new doctors to practice for two years in underserved areas.
Our urgent need to scale up infectious disease control is not unlike the impetus for the Green New Deal (GND) jobs & infrastructure proposal to support a just energy/climate transition.
Our urgent need to scale up infectious disease control is not unlike the impetus for the Green New Deal (GND) jobs & infrastructure proposal to support a just energy/climate transition. Both ideas draw inspiration from President Franklin D. Roosevelt's response to mass unemployment in the Great Depression by creating the Works Progress Administration which hired millions of unemployed people over an eight-year period for public works projects.
Clearly the need to address the climate crisis remains urgent, but first we have to get out of the house safely. Jeremy Brecher, of the Institute for Policy Studies, has called for such an emergency GND that includes health. Such a new health corps could offer a win-win solution to our two acute (and simultaneous) dilemmas: record levels of unemployment and a vital need for more feet-on-the-ground to reduce our viral case load.
At present, many political observers predict that after the pandemic, citizens will demand more investment in health care and disease surveillance. Thus, a plan to strengthen health staffing--including new professional and community health workers--could address future needs as well as our current emergency. Besides containing new infections and providing vital paychecks to our unemployed, like other "essential" workers, new health workers would spend their funds into the economy boosting demand for goods and services.
Dr. Frieden argued in early May that lockdowns, while effective at stopping spread, are blunt tools that cause unemployment and bankruptcies. Instead, he said, "we have a sharper tool, (a strategy) to stop chains of transmission by widespread testing, isolation of cases, contact tracing and quarantine of contacts."
Frieden, who now directs the non-profit Resolve to Save Lives, gained extensive experience overseeing responses to the H1N1 influenza, Ebola and Zika epidemics while running the CDC. But the importance of contact tracers was brought home to him many years earlier in New York City. I did post-doctoral research in 1999 comparing two epidemics of resurgent multi-drug-resistant tuberculosis (MDR-TB) - one in New York City and one in Lima, Peru. I learned that Frieden, while working in the CDC's Epidemic Intelligence Service in 1991, helped demonstrate that MDR-TB was widespread in many poor neighborhoods of New York City, a finding that spurred the mayor to replace city health officials who had ignored mounting signs of the epidemic.
Frieden was appointed to lead the city's tuberculosis division and later credited for innovative policies thar brought the deadly outbreak under control. One key initiative was the hiring and training of community health workers (who did not have professional degrees) to do outreach, track cases and administer doses of anti-TB drugs, effectively cutting the chain of contagion and drug-resistance.
Community health workers were also the key to controlling MDR-TB in Peru. TB drug resistance was first identified in a barrio of Lima in the late 1990s by the Boston-based non-profit Partners in Health (PIH). Drs. Paul Farmer and Jim Yong Kim, who directed PIH, built a program at an urban clinic in Lima to address the deadly outbreak using a similar strategy of outreach and treatment with lay workers doing home visits and social programming with patients. In both the New York and Lima epidemics, a training staple for successful community outreach was cultural sensitivity and a willingness to establish relationships and trust with patients and their families. PIH's Peru work helped established a model for treating MDR-TB outbreaks in low-income countries.
PIH is now applying that experience to COVID-19 in Massachusetts where the health department recently contracted with PIH to hire 1,000 fulltime community health workers as half of a 2,000 person contingent who will do contact tracing statewide. Another model may be California which has invested in a well-designed disease tracking system, and now aims to combine hired staff and volunteers to ramp up to 10,000 contact tracers.
Since April 1 new US cases per day have exceeded 20,000 on every day except one, and have ranged as high as 38,000. Epidemic models predict the infection will continue to spread across the country in the months ahead, producing not hundreds of thousands, but millions of new infections, especially in places where social distancing is lax. Many states project using new electronic tracing systems for COVID-19 exposure which have been heavily hyped by tech companies, such as Google and Apple. But even if the serious privacy concerns raised by these apps are resolved, such systems will only be an aid, not a replacement for humans who follow-up with contacts exposed to the virus.
The work of a contact tracer, ideally hired from the same area where he or she would serve, starts with interviewing infected patients and following leads to find people that person was recently in contact with. These workers then help arrange testing for new contacts, advise them on self-isolation, and assist those who become sick with treatment and access to humane quarantine options like hotel rooms or other facilities for patients in crowded households so as to avoid infecting immune-compromised or elderly members. Support for patients in quarantine would include food and daily follow-up on medical needs. This level of support is the only way to prevent super-spreader events--such as the widely reported outbreaks at funerals or nursing homes that contributed to the US having a quarter of all reported cases globally.
When locally-based and trained well, community health workers are also the ideal outreach personnel to educate others on coronavirus prevention and treatment, including advice on chronic problems that contribute to high COVID-19 mortality rates in Latino and Black families. In the long run such a workforce could help address the long-standing shortage of primary care in the United States--including community-based programming to assist families with preventive health, nutrition, exercise, chronic diseases and mental health needs.
In their public letter, Drs. Gottlieb and Slavitt called for $46 billion in national support for states to trace contacts and isolate infected patients, with an additional $4.5 billion for quarantine facilities, including rental of otherwise vacant hotel rooms. While the last Congressional stimulus package (HR 266) contained $25 billion for state health departments, the bulk of those funds were aimed at scaling up testing, with only a small slice likely to be spent for tracing contacts.
To re-open safely, the country needs a more comprehensive approach. One promising bill, introduced by Sens. Kirsten Gillibrand (D-N.Y.) and Michael Bennet (D-Colo.), would allocate $55 billion a year for a new "Health Force"--training and hiring hundreds of thousands of new public health workers to do testing, contact tracing and eventually vaccinating the population. The Senators even cite FDR's Great Depression work program as an inspiration.
It is clear that re-opening alone will not rapidly reduce unemployment, and federal stimulus efforts to date to keep working people afloat are woefully inadequate. The country needs to look beyond welfare solutions. There is much work to be done. Why not hire the unemployed to find and stem new viral outbreaks so we can reopen without recurring waves of deadly outbreaks? Until we have an army of disease detectives, the virus will continue its massive crime wave.
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No, We're Not All in This Together. How the Super-Rich Are Cheating America.
Unlike the farsighted and people-oriented decision-makers in other countries, America's unregulated capitalist leaders have failed us, both in the past and in our current crisis.
Apr 27, 2020
Media outlets keep telling us that we're all together in this pandemic. But we're not. The super-rich have separated themselves from the rest of us, with concierge medicine, private travel accommodations, isolated but well-stocked resort homes, and a variety of other advantages that allow them to look beyond the hardships endured by average Americans.
A few billionaires have contributed to the fight against Covid-19. But Luke Hildyard, Executive Director of the High Pay Centre, says, "Very generous individual grants can obscure the fact that on the whole, wealthy people's charitable giving is pretty minimal." In the most flagrant example of disregard for the rest of us, one company has installed private 'doomsday' bunkers in New Zealand with "luxury bathrooms, game rooms, shooting ranges, gyms, theaters and surgical beds."
There are at least three good reasons why wealthy Americans should be doing a LOT MORE to give something back to the nation that made them rich.
A Guaranteed Income Held Hostage: The Richest 5% Own Almost Two-Thirds of Our Nation's Wealth
The richest 5% have an average net worth of over $5 million. They came away with nearly $35 TRILLION dollars in the past ten years, mainly by waiting out the stock market, which has more than tripled in value since the recession. In the ten years from 2009 to 2019, the average member of America's richest 5% more than doubled his/her wealth from $2.6 million to $5.4 million.
Stock growth represents American prosperity. Everyone should benefit, probably by receiving a guaranteed income. Just a TWO-PERCENT TAX on total financial wealth would generate enough revenue to provide nearly a $14,000 annual stipend to every American household (including those of the richest families).
Big Tech and Big Pharma are Worth Trillions. They Were Built by the Taxpayers, Most of Whose Descendants Have Been Living Paycheck-to-Paycheck.
Bezos & Gates & Zuckerberg were "standing on the shoulders of giants" when they started their companies. The tallest giant was the U. S. taxpayer, who paid for 70 years of government research to develop all the technology that a few well-positioned individuals eventually claimed as their own.
The tallest giant was the U. S. taxpayer, who paid for 70 years of government research to develop all the technology that a few well-positioned individuals eventually claimed as their own.As Gar Alperovitz noted, "Between the mid-1980s and the mid-1990s the National Science Foundation spent $200 million to build and operate a network of regional supercomputing hubs called the NSFNET. Connected to the ARPANET, this network established Internet access for nearly all U.S. universities, making it a civilian network in all but name." Government funding for technology goes back much further, as explained by Mariana Mazzucato: "From the Internet that allows you to surf the Web, to GPS that lets you use Google Maps, to touchscreen display and even the SIRI voice-activated system -- all of these things were funded by Uncle Sam.."
But instead of returning some of this nationally-generated wealth to the millions of people living paycheck-to-paycheck, the billionaires keep taking more. As documented in the new Institute for Policy Studies report Billionaire Bonanza 2020, tech billionaires are even profiting from the pandemic!
In a similar vein, pharmaceutical companies wouldn't exist without money from the taxpayers, who have provided support for decades through the National Institutes of Health, and who still pay for most of the basic research for new drugs and vaccines. Yet both the tech and pharmaceutical companies claim patents on the products paid for and developed by the American people. And now, as author Gerald Posner puts it, "Pharmaceutical companies view Covid-19 as a once-in-a-lifetime business opportunity."
The Super-Rich Will Help Themselves by Leading the Fight Against Future Pandemics
Largely because of their lack of wealth and resources, African-Americans and people of low income have been much more severely impacted by COVID-19.
But a future pandemic could be even more virulent, reaching further into havens of wealth. The super-rich have to realize by now that by supporting a social need they're protecting themselves from global catastrophes. Not only from viral epidemics, but also from environmental disasters and terrorism. Sonia Shah, author of the 2017 book Pandemic, warns us that our negligent environmental policies make it more likely that a previously harmless microbe will cause a deadly outbreak. And as for the threat of terrorism, Dr. Ali S. Khan, author of The Next Pandemic, notes, "A deadly microbe like smallpox -- to which we no longer have immunity -- can be easily recreated in a rogue laboratory."
So for rich and poor alike, a commitment to anti-viral and infectious disease research is needed to reduce the threat of future pandemics. As Fortune explains, "Today, infectious diseases are emerging and reemerging more quickly than ever before. Between 1980 and 2013, the number of annual epidemics has gone from fewer than 1,000 to over 3,000. Infectious diseases such as Zika, MERS-CoV, SARS, cholera, tuberculosis, HIV/AIDS, influenza, and Ebola kill millions every year, and their outbreaks have decimated economies and triggered aftershocks and panic around the world."
Who's to Blame for America's Failures?
Unlike the farsighted and people-oriented decision-makers in other countries, America's unregulated capitalist leaders have failed us, both in the past and in our current crisis. We're not "all in this together" when so few people own so much of the wealth. And the state of our nation's health could easily get worse. As Noam Chomsky recently explained, "There's no profit in preventing a future catastrophe."
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Let's Come Together in These Physically Distancing Times
"As bad as things are, and could get, compassion and wisdom will ensure that good emerges from this."
Apr 04, 2020
These are difficult times, especially for people who lack safe shelter, food and other necessities -- and for those on the front lines. Even though we must maintain physical distance, we need to come together more than ever.
As bad as things are, and could get, compassion and wisdom will ensure that good emerges from this. One hopeful trend in recent years is a growing recognition of the need to combine science with traditional Indigenous knowledge to get a more complete understanding of our place in nature and to find better ways to live within its limits.
People who have been connected to place for millennia often have a clear comprehension of how ecosystems work, of the importance of every component of the interconnected webs of which we're all a part. Western science tends to be reductionist, focusing things in isolation, often under controlled or artificial conditions such as flasks and growth chambers.
That can lead to unintended consequences. For example, Paul Mueller won the 1948 Nobel Prize in Physiology or Medicine for developing the powerful pesticide DDT. Although the compound effectively stemmed malaria and other insect-borne diseases, scientists missed the big picture until 1962, when Rachel Carson sounded the alarm in her book Silent Spring. Indiscriminate DDT application exterminated "pests," but the chemical also bioaccumulated in the food chain, killing birds and working its way into other animals, including humans.
This reductionist mindset also holds true for much of Western economics. Forests are seen only for their value as timber, not as communities of organisms that also provide irreplaceable services and benefits to people, from clean air and water to climate regulation -- even disease prevention.
As mentioned in last week's column, forest and habitat destruction is partly responsible for the fact that 60 per cent of emerging infectious diseases since 1940 (including HIV, Ebola, Zika and a number of coronaviruses) originated from animals -- two-thirds from wildlife and the rest from pets and livestock.
Growing research shows the importance of taking a holistic or systems approach to science and economics, and of learning from and working with Indigenous Peoples who have place-based knowledge from thousands of years of observation and experience.
Can we apply this thinking to find a better path from this crisis than the one we're on? I think we can.
Looking at all the good already around us, we see that most people care for each other and want to do the right thing. Altruism is spreading faster than any disease can -- and what is altruism but the innate recognition that we're all interconnected with each other and interdependent on all of nature?
We see front-line people in positions that aren't easy at the best of times -- health care, emergency services, grocery and food industries, mental health and more -- going above and beyond to make sure most of us are safe and fed.
In Canada, we're fortunate to have leaders at all political levels and in the health system keeping us informed and doing their best to help us through this.
Most people are willing to accept the restrictions placed on their lives so that we can overcome this emergency. Many are going out of their way to help neighbours in need. People are emerging onto their balconies or yards to sing or cheer for those who are making extraordinary efforts to keep the health care and food systems going strong.
In other words, people overall are more good than bad, and that should give us hope.
Yes, there are those who will act out of selfishness, or whose ignorance compels them to ignore anything not in their immediate interest. Unfortunately, some wield power and will do all they can to keep us on the same narrow, dangerous path. It appears plans are already in the works to bail out industries that should have been winding down long ago.
We're facing a crisis trifecta: COVID-19, climate disruption and plunging oil prices sparked by a feud between Russia and Saudi Arabia. This is exposing flaws in the systems we've been relying on far beyond their best-before dates.
Now, more than ever, we need to take care of ourselves and each other, so that we can help steer humanity onto a better course. We're showing we can do it.
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