Using containment as a public health strategy can identify positive, preferably presymptomatic, COVID-19 patients and put them into isolation. This approach was successful in other countries when numbers were low and testing was available, but was not done in the United States because we had insufficient testing.
The United States switched to a mitigation strategy to flatten the curve, which was primarily designed to decrease the rate of disease and spread it out over time to preserve critical life-saving human resources and materials, such as ventilators and ICU rooms.
Fifty-thousand Americans lost their lives in little over a month, and that number is rapidly climbing. These deaths in certain geographic hotspots caused widespread panic and forced a national lockdown with masks for everyone. While many concerns remain about a second wave or viral mutation, it appears that we have indeed flattened that curve.
Of course, there was a lot of political Monday morning quarterbacking about how the liberal media politicized and overplayed COVID-19, causing unnecessary lockdowns and destroying local economies for something not much worse than the seasonal flu, and conversely how the President's neglect to prepare the nation in advance, his failure to test sooner, and his lack of caution and honesty in addressing Americans cost thousands of human lives that would have been saved by a different leader.
Either way or both, we can no longer keep talking over this fence with inaction. A devastated economy will destroy lives as will a rebellious disregard for restraint. We need a rational strategy now that is acutely cognizant of protecting everyone's health and life as well as regenerating a healthy economic environment.
Much like health insurance, it comes down to which risk is an individual or an employer willing to take and which data are available to inform that risk. The answer lies in what we now have—tests. But any calls for testing anybody who wants it is naive to the limited resources that new demands would quickly deplete, not to mention that the costs will be high and the logistics of universal testing impractical. And we know the most disadvantaged are the least likely ever to get testing. This test-everyone idea is not a strategy; it is an emotional reflex, a farcical optimism, a capitalistic venture, and a political diversion. The antibody tests are unreliable, and we do not have enough materials to do PCR tests on anyone who wants it.
Instead, I offer an initial business strategy. The majority of U.S. adults are employed and live asymptomatically in low-prevalence areas. We need to prioritize employees and get them back to work without ignoring the real fears and emotional weight COVID-19 has placed on people at work and in their homes.
A Wellness Issue
Businesses should perform testing locally with groups of less than 20 people who work in close proximity. Promote testing as a wellness issue to have the emotional freedom and physical safety in the workplace and at home. In low-prevalence areas, you are testing to have the certainty of what you think is probably already true.
Swab 10-20 employees on a Friday at 3 p.m. (Our hospital lab can currently do 12 at once. It is apparently a function of how many swabs you can fit in the medium.) Batch them all together and do one PCR COVID-19 test. Using PCR in a low-prevalence area among asymptomatic persons, everyone comes to work Monday morning if the test is negative. This is by far the most likely outcome, costs about $100, and takes about an hour to do (depending upon whether a lab is nearby). Maybe you do this once a month for two or three months. Then reassess. (Batch testing can also be done in nonemployee environments like homeless shelters, nursing homes, and jails, to lower the enormous cost and use of resources.) If you work in an ED, you could do this more than once a week.
If you happen to have a positive result, split the group in half and test each half with one test, and repeat splitting the group until you find the positive person who goes into 14-day isolation. The worse-case scenario is using six or seven tests instead of 12 to 20 to keep your employees and customers safe. The best-case scenario, and by far the most likely, is that you use only one test to give people safety and emotional freedom in the workplace.
We flattened the curve with a widespread aggressive, though late, mitigation strategy, and now we must play local viral whack-a-mole as a containment strategy in low-prevalence areas. Reframing the strategy as a revitalization of business by local employers to provide emotional and physical safety in the workplace through batch testing, it will have a much higher buy-in than a government recommendation would.
Without a prompt, clear, reliable (PCR), and available strategy for safely re-entering the workplace, Americans will simply make their own decision (many already have). Deciding for yourself which risk you are willing to take could not be a worse public health strategy, especially if COVID-19 creates a second wave with multiple curves that must be flattened throughout the United States.
Everyone talks about wellness among front-line providers, and there is grave concern for suicide risk among emergency providers. Yesterday, we were willing to risk our lives. Today, we are being dangerously understaffed to make up for the economic loss. We need to change the hospital banners to read, “Heroes who were furloughed worked here!”
Our emotional wellness is arguably worse now than it was during the first few adrenaline-powered weeks of threat. Why wouldn't we provide emotional wellness now by doing regular batch testing of the ED staff and surveillance among staff most likely to come in contact with our most vulnerable patients in the community? Note to hospital: If you want to thank us for being your hospital's heroes, then test us and staff us for the emotional and physical safety of the emergency department.
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Dr. Mosleyis an emergency physician in Wichita, KS.