On the plus side, if Covid-19 actually has many more cases undetected in the world, that could mean it’s less deadly than people might fear (because, as my colleague Maryn McKenna points out, there hasn’t been a concomitant spike in pneumonia and other serious illness). The “cryptic” infections, the ones no one knows about yet in the US, might be mild.
But the outbreak’s progress in other countries at least suggests that some number of people who get infected need hospitalization. No one knows what percentage that is relative to the total number of infections, but if it’s large, that surge could overwhelm a hospital. Social distancing measures could keep the surge to an ebb. “The term I’ve been using is ‘metering,’” says Wendy Parmet, director of the Center for Health Policy and Law at Northeastern University. “Hopefully if you’re slowing it down, maybe more people are sick at the other side of our knowledge curve about treatment.”
Social distancing measures would be managed by state and local public health agencies—the same places that have had their budgets cut to the marrow in recent years (a loss of 10 percent of federal funding and 55,000 jobs in the last decade, according to one report). They’re not ready to handle the knock-on effects of wide-scale social distancing without help. “There has been, historically, inadequate thinking about how we can make it feasible, plausible, for people to work at home, to keep their kids out of school, to make it possible to meter the rate of transmission,” Parmet says. “In the early 2000s, after 9/11 and SARS and Ebola, we kind of put a new coat of paint on our quarantine laws, and in 2017 the CDC promulgated new quarantine regulations. But we didn’t do the other stuff. We didn’t enact sick pay laws or unemployment protections. We didn’t develop plans for how to get medicines to people.”
The American healthcare system, in fact, got worse—with built-in incentives to keep people from seeking help until their need is urgent. “Part of the thinking of our healthcare system is that people should have skin in the game,” Parmet says. “But even if everything about that is as the health economists who advocate it assume, it’s a disaster in an outbreak.” It means people who might be sick—even people who might suspect they should get tested—are themselves disincentivized from seeking out care because they can’t afford it. So they keep spreading the disease in the community.
The US government has made it easier to develop countermeasures against bioterror and to stockpile medicines and protective equipment, but hasn’t done what Parmet calls the “gritty work” of supporting people so they can comply with emergency measures. “You want people to be able to comply, and we haven’t dealt with that,” she says.
The most frustrating part of this problem is that it is eminently solvable. An open letter from more than 400 public health and law experts sent to Vice President Mike Pence—head of the government’s coronavirus efforts—laid out some of what has to be built into mitigation efforts. “The clear issue is, we have to manage the costs of this,” says Scott Burris, director of the Center for Public Health Law Research at Temple Law School and, like Parmet, a signatory on the open letter. He suggests things like extending food stamp programs to people who get told to stay away from work, or to provide unemployment benefits—or just straight-out cash payments. A key move would be to at least temporarily mandate paid sick leave at companies with more than some threshold number of employees—a move that almost always improves individual and public health. “Someone’s got to figure out how they’re going to do it, because if they don’t, it’s going to be inequitable and ineffective. Equity and effectiveness go together in these situations,” Burris says.