BY LARA SANTHANAM / PBS NewsHour
Seven months since cases of the coronavirus were first reported, some countries have effectively combatted the virus and brought the spread under control. The United States is not one of them. But experts say it’s not too late.
Americans account for roughly a quarter of the more than 551,000 global deaths from COVID-19 so far — far more than any other country, according to the latest global data from Johns Hopkins University. A number of states, as well as the country as a whole, have begun breaking daily records repeatedly for newly confirmed cases, and Florida reported on July 9 that more than 80 percent of its hospital ICU beds are filled.
In contrast, New Zealand had declared COVID-19 eliminated inside its borders by early June. People returned to sporting events and nightclubs. Nationwide, the virus killed 22 people overall.
Cars line up for coronavirus testing outside Hard Rock Stadium in Miami Gardens, Fla. Florida is one of many states reporting spikes in COVID-19 cases in recent days, as the number of confirmed cases worldwide has topped 10 million.
CREDIT: Wilfredo Lee/AP
During the early days of the pandemic, public health officials in that country calculated that COVD-19, a coronavirus like the common cold and SARS, could be snuffed out, but it would take extreme measures to do so. The entire country had to enter lockdown, health experts advised the country’s leadership, who trusted science over all else. New Zealand Prime Minister Jacinda Ardern relayed to her nation what public health experts had told her. That approach “brought people with us,” said Dr. Michael Baker, an epidemiologist and professor at the University of Otago who helped craft the COVID-19 strategy for New Zealand. It was a harsh thing the country had never done before, he said. Criticism pushed back against lockdown, saying Ardern and others were using “a sledgehammer to kill a flea,” Baker said. “It was definitely a sledgehammer, but not a flea. It was a very significant pandemic.”
For seven weeks, New Zealanders stayed home to stay safe and not overwhelm the country. The effort paid off.
Meanwhile, as cases mount, the U.S. government has maintained a hands-off approach, said Dr. Ashish Jha, who directs the Harvard Global Health Institute. That lack of national cohesion has left states to fend for themselves in figuring out how to best keep the virus in check, navigating shortages of protective gear and testing supplies, and deciding when and how to reopen. The result is a patchwork of responses, with some adopting more aggressive tactics, while others have taken far fewer measures — and seen their infection rates rise.
The U.S. is not the only country to downplay the virus: Brazil currently ranks second only to the United States in cases and President Jair Bolsonaro confirmed this week he has tested positive.
“In general, ignoring the virus, or taking a laissez-faire approach to the virus, ends up not being a good strategy,” Jha said. “It really ends up being quite harmful.”
What strategies have been shown to work, but that the U.S. has not adopted on a wide scale? The PBS NewsHour asked public health experts for tactics that could still make a difference in saving lives.
1. A clear, consistent message
Japan identified its first cases of novel coronavirus by mid-January. Five weeks later, the country closed nearly 35,000 schools for almost 13 million Japanese schoolchildren for several weeks. By April 16, the nation declared a state of emergency.
Dr. Hitoshi Oshitani, a virologist and public health expert in Japan who helped shape the country’s COVID-19 strategy, said investigators there set out around that time to understand where outbreak clusters were happening. If patterns emerged in their data, then officials could warn the public accordingly. Officials studied more than 3,100 confirmed cases of COVID-19 from January to April and found 61 clusters where five or more people who didn’t live with each other were infected.
Most often, public health officials traced outbreaks of viral infections to three settings:
- Closed spaces with little or no ventilation
- Crowded places with people packed together
- Close contact, such as intimate conversation, singing or cheering
People put themselves at greatest risk when those three settings — which became known as the Three C’s — all overlapped. That means lingering in indoor places like health care facilities, workplaces, live music venues, gyms and karaoke bars put people at heightened risk for being exposed to the virus.
“Without a cluster, the transmission chain cannot be sustained,” Oshitani said.
From these common characteristics, Japan created an easy-to-understand campaign that “managed to send a more effective message to the general public.” The Three C’s are so simple, Oshitani said, that most elementary school students know and understand them.
And that distillation of evidence-based guidelines on social distancing into easy-to-understand rules has been key to Japan’s ability to keep COVID-19 infections below 20,000 cases and deaths to fewer than 1,000 people during the last six months.
The message is gaining traction. The World Health Organization has adopted Japan’s Three C’s to raise broader public awareness of the continued need to avoid risky environments and prevent further outbreaks.
Throughout the pandemic, Japan’s streamlined messaging has helped get vital information to the public, Oshitani said. National government officials use input from the scientific community to develop and issue basic guidance to local authorities, and communities can then tailor those guidelines to fit their needs and resources.
It is also important to have a common strategy or at least basic policies within a country, Oshitani said. If Tokyo and Osaka used widely different strategies to rebound from COVID-19, and Tokyo was successful but Osaka wasn’t, “we have many people traveling between Tokyo and Osaka,” he said. “Then, Tokyo cannot be safe if Osaka has many cases.”
Effective messaging is critical to public health, said Dr. Natalie Dean, a biostatistician and professor at the University of Florida who studies emerging infectious diseases. “Convincing people to take the individual action — that will keep our communities safe.”
Instead, within the U.S., the public hears “a cacophony of messages,” said Dr. Jared Baeten, an epidemiologist at the University of Washington. This is not how the nation’s public health infrastructure has typically responded to crises, he said, in part because “public health messaging is not flowing from the top right now.”
Messages about COVID-19 coming from the Trump administration — and from the president himself — often conflict with science and the advice of leading public health officials. On Feb. 27, when the number of known cases in the U.S. was still in the double digits, Trump told reporters that within a couple of days the number was “going to be down to close to zero.” Less than a month later, the U.S. reported nearly 3,500 confirmed cases and 68 deaths.
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Trump repeatedly promoted the use of unproven medications, including hydroxychloroquine, despite the fact that no clinical trials had been completed to determine if the drug was safe to treat COVID-19 patients. He has flip-flopped in his support of face masks — a measure that growing scientific evidence suggests could prevent the virus from spreading — while rarely wearing one in public himself. And this week, Trump criticized the CDC’s own recommended protocols for how to safely reopen schools at a time when parents, educators and communities across the country are deeply concerned about how and when students can return to the classroom. The agency said it would not water down its guidelines.
“This virus is relentless,” Baeten said. “It capitalizes on our confusion and our discord.”
2. Mask up
Not long after Vietnamese health officials detected COVID-19, the nation mandated that people wear face masks on public transportation and while out and about.
Those efforts may have helped to slow the spread of the virus. So far, fewer than 400 people have been diagnosed with COVID-19 in Vietnam, and no deaths have been linked to the virus, according to data from Johns Hopkins University. As many as 50 countries have adopted similar measures, including Germany, France and Italy. A growing body of evidence suggests face masks block droplets of spit and mucus that can spray when one talks, sneezes or coughs, slowing the spread of COVID-19.
In the U.S., the response to face masks has been mixed. By mid-May, 15 states and the District of Columbia made masks mandatory in public spaces where social distancing wasn’t possible. According to a study published in the journal Health Affairs that compared the new infections in states that mandated masks to those that hadn’t, the authors said, “There is a significant decline in daily COVID-19 growth rate after mandating facial covers in public, with the effect increasing over time after signing the order.”
Altogether, the study authors estimated that face mask mandates may have prevented as many as 450,000 COVID-19 cases in the U.S. this spring.
In Arizona, where more than a quarter of all people tested for COVID-19 are positive (the highest positivity rate in the U.S.), Gov. Doug Ducey has urged but not ordered residents to don face coverings, despite the state’s medical community pressing him to do so weeks ago. Several cities already had mandated masks.
3. Contact tracing
Public health officials have consistently said the U.S. needs to do three things well to mitigate coronavirus: test people to see who is infected, isolate people who are sick so they don’t spread illness to others, and trace the contacts of those who are infected.
The Care19 mobile app, which the governors of North Dakota and South Dakota have asked residents to download to assist in contact tracing during the global outbreak of the coronavirus disease (COVID-19), is seen on a phone in April 24, 2020. CREDIT: Paresh Dave/Reuters
When results come back positive, a patient’s information gets funneled to state or local public health departments, and workers will ask the patient who and where they may have had recent contact. Did they go to the grocery store? Visit family or friends? Report to work? The health department then calls whoever comes up on that list to let them know they need to get tested and isolate themselves until they receive their results. Eventually, this strategy boxes in the virus.
South Korea and Taiwan have both stood up tech-driven contact tracing efforts to monitor the virus and get ahead of outbreaks. And both countries have effectively contained the virus, although cases have recently risen from 10 to more than 50 in South Korea, said Haksoo Ko, professor at Seoul National University School of Law and who has studied the nation’s COVID-19 rebound early on during the pandemic. He said centralized contact tracing, including digital apps on people’s smartphones, “has been instrumental in coping with the spread of the virus in South Korea,” bolstering public health efforts but compromising privacy.
Yet contact tracing in the U.S. is far from where it needs to be, Baeten said. Why? Because it’s harder than it sounds. People may not always pick up their phones, especially as so many are wary of spam calls from unknown numbers. People may not remember (or be forthcoming) about where they have gone or with whom they interacted. And when states have few trained contact tracers trying to contain a rapidly spreading virus, the odds don’t look great. Missing data and paper test results that have plagued the U.S., also slow that process, causing public health officials to lose critical time.
Another problem is that the nation just does not have enough people working as contact tracers. On June 25, Dr. Robert Redfield, director for the Centers for Disease Control and Prevention, said nationwide there were nearly 29,000 contact tracers, up from about 6,000 in January. But during that press call, Redfield said he “estimated the nation needs close to 100,000.”
A handful states have launched optional smartphone apps to help streamline the process of manual contact tracing, pairing people’s anonymous location data with public health department records to see who may have been infected where and when. But it’s a tricky proposition, shadowed by people’s uneasiness about being surveilled, questions about whether these apps accurately register people’s locations and what is known about the duration of contact necessary to pass the virus to another person.
As new cases explode in Florida, contact tracers have reportedly had a hard time identifying and reaching all of the people who have recently attended large house parties. According to The New York Times, Florida has about 2,200 contact tracers for the entire state — about a third of the number recommended.
What’s next?
Thinking about what the next six months may bring, Jha said he anticipates a tale of two countries within the U.S.
Some states won’t take the virus seriously or won’t act aggressively to contain the spread of infection, and as a result, “you’re going to see large outbreaks, and unfortunately, a lot of people will be getting sick and dying,” Jha said. Other states, such as California, Massachusetts, Ohio and Michigan, will continue to ramp up testing, enabling them to spot and stamp out potential outbreaks earlier.
But strict vigilance among only some states — while others operate with more lax rules — will ultimately not help stamp out the virus in this country. “They’re not going to be as effective as they could be if we had a federal effort,” Jha said.
And yet, Jha doesn’t see a hopeless situation for states that haven’t acted aggressively yet. “It’s going to be hard, but I think they’re going to get there. It’s going to take a lot more work than is necessary.”
It’s not too late for the U.S. to change course, echoed New Zealand’s Dr. Michael Baker.
Baker said New Zealand officials initially surrendered to the inevitability of the virus and pandemic. In March, they watched as COVID-19 crushed Italy and waited to see what would happen to their own island nation. But then Baker said he had a “lightbulb moment where you look at what’s happening and your consciousness has a profound shift.”
“It took a very brave government,” he said. “You say, ‘We’re going to tell the entire country to go home and stay home for many weeks’” despite the potential for economic damage.
Since getting to zero, New Zealand has seen a couple of new cases among travelers, but continues to deploy quarantine measures and contact tracing to keep it under control.
To reverse the troubling trend in the U.S., Baker said the country needs decisive leadership steered by science. To that end, he said the U.S. must move on three strategies: manage its borders, suppress infections with lockdowns and mask-wearing and operate far more extensive testing and tracing efforts.
“Those are the three things New Zealand did,” he said. “Anywhere in the world can do that. Many places have. There’s nothing special about New Zealand.”
During past public health crises, Baker said the world looked to the U.S. for leadership. He said that sadly hasn’t happened under COVID-19, adding, “I hope the U.S. will resume its world leadership role. It’s been a power for good.”
During a July 7 press conference, Dr. Tedros Adhanom Ghebreyesus, director-general for the World Health Organization, noted that the virus is spreading faster, the pandemic has not yet peaked, and the world “cannot afford any divisions.”
That same day, the Trump administration signed the formal letter that initiated the U.S. withdrawal from the WHO, something legal scholars say the White House is not authorized to do. A senior White House official confirmed to the PBS NewsHour that the letter was sent to U.N. Secretary-General António Guterres. The letter begins a year-long process that could make it harder for the CDC to communicate with their counterparts abroad during a global pandemic.
Secretary of State Mike Pompeo said during a July 8 press briefing that the U.S. remains “a world leader on the pandemic. It almost goes without saying.”
If the U.S. withdraws from the WHO, the decision will be nothing short of “a disaster,” Baker said, in part because the globe has nothing else to replace the public health organization, which operates on a limited budget already. Now more than ever, he said, the world needs to work together.
“It’s just in our mutual interest to manage these pandemics early and effectively,” Baker said. “That way, local outbreaks may never become global pandemics.”
