One step forward, 2 steps back: Harvard's Dr. Thomas Tsai assesses Trump's response to COVID-19, and tells us his fears and hopes about the months ahead

  • Dr. Thomas Tsai, of the Harvard Global Health Institute, spoke to Business Insider about where the United States stands in the fight against COVID-19 and President Donald Trump's claim to be leading the world's best response.
  • "It's as if we are taking one step forward and two steps back," Tsai said of the US response to the pandemic. "We started off with a peak, we settled for a plateau, and we ended up with a mountain range."
  • "We're breaking records every single day on state-level and national-level positive tests. What that means is that in one to two weeks from now, those record numbers of cases may translate to an increasing number of hospitalizations, ICU admissions, and, unfortunately, even fatalities."
  • Dr. Tsai said President Donald Trump's approach has left much to be desired. "Right now, at the highest peak of cases that we've had, it's also been where the federal government has been most absent, where there has been no White House coronavirus task force briefing."
  • "This pandemic has clearly shown the failure of a patchwork response and the result of a vacuum in terms of a national coordinated strategy."
  • He faulted leadership in some states, such as Florida, for being unwilling to close down when necessary.
  • "Politicians are unwilling to dial things back. They're only willing to sort of keep it from moving forward. Clearly, in the states where the pandemic has gotten out of control, a limited shutdown is needed to prevent hospitals from being overrun."
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Not only are a record number of Americans testing positive for COVID-19, but, contra President Donald Trump's false claim that the US has the lowest mortality rate in the world, more and more of them are dying, even with improvements in care. In the South, former success stories, such as Florida and Texas, are seeing a surge in infections — the consequence, experts say, of reopening their economies without first building up the capacity to test, trace, and quarantine.

Over 131,000 people have now died from COVID-19, which is certainly an undercount, not including those who died without ever being tested, nor those who were unable to get treatment for other disorders as a result of hospitals being overrun by a pandemic. Fourteen states have seen a double-digit increase in their coronavirus mortality rate over the last week, according to a count from The Washington Post, and, by the end of the month, the US Centers for Disease Control and Prevention projects the death toll to be as high as 160,000.

Dr. Thomas Tsai, a professor at Harvard University's School of Public Health, feared this would happen, warning that happy talk of a speedy recovery was only masking the severity of the crisis. A member of Harvard's Global Health Institute, he told Business Insider this week that the United States is even worse off than it was in the spring — "It's as if we are taking one step forward and two steps back" — and that if Trump wishes to boast of his handling of this crisis, he would have to let scientists take the lead, and use the full power of the federal government to mobilize a national response.

This transcript has been lightly edited for clarity.

Charles Davis:

In March, you said, "There is a true fear that we may emerge as the new epicenter for the global pandemic." What made you fear that then, and where do you think we are today?

Dr. Thomas Tsai:

Back in March, the fear was driven by the lack of preparation in both, at that time, the testing capacity as well as the ability to treat the patients in terms of hospital capacity, our supply of PPE, and even ventilators. What's frustrating is that, four months later, we're back to having the same exact conversation, if not on a national level, at least on a state-to-state level.

So we're back to talking about testing capacity issues in some of our southern states, tests that take over one to two weeks to get back the results from. We're back to talking about crisis standards of care, which is rationing of hospital ICU beds. We're back to talking about test positive rates that are reaching almost 10% again. So it's not even we're taking two steps forward, one step back. It's as if we are taking one step forward and two steps back. The current peak now is higher than the peak that was in April. 

We started off with a peak, we settled for a plateau, and we ended up with a mountain range.

Davis:

You also lead an effort to project COVID-19 hospitalization rates. We were talking about how we're at a mountain peak right now — what do you expect we'll see in the months ahead?

Tsai:

So my fear is that with the hospitalizations that we're seeing now, they're actually reflecting the community-level transmissions that were occurring about two weeks ago. But the surge in cases hasn't gone down over the last two weeks. They've actually gone the opposite direction. We're breaking records every single day on state-level and national-level positive tests. What that means is that in one to two weeks from now, those record number of cases may translate to an increasing number of hospitalizations, ICU admissions, and, unfortunately, even fatalities.

The challenge with balancing hospital capacity was that in March, there was a concerted effort to truly flatten the curve, with hospitals around the country postponing elective surgical procedures and medical admissions to free up beds for the anticipated wave of COVID-19 patients. What we couldn't have predicted was how variable the transmission curves would be state-to-state. So instead of one peak, we basically have had 50 different state trajectories with 50 different peaks, all occurring at different points.

Right now, in these southern states, we're at a critical moment where hospitals are busy trying to take care of patients with non-COVID conditions that were postponed and deferred appropriately during March, April, or May, but now they have the double burden of also trying to address the current rise in the COVID-19 cases. In some ways, it's sort of a perfect storm in some of these southern states.

Davis:

I've been covering Florida a lot recently, and some of the doctors I've spoken to there have attributed the most recent surge to the fact that the state opened up so early without developing the capacity to test and trace positive cases in their contacts with others. That makes sense to me. 

But then I look at California, which is also surging right now, and at least early on, the story was that California was doing this the right way. We shut down early. We did not reopen early. So I guess what explains California? How do we reconcile the fact that California seemed to do it right, Florida seemed to do it wrong, but they're kind of having the same outcome now?

Tsai:

Right. California is a challenging state, because it's the United States in microcosm. It has very urban areas, very rural areas. It has areas that are medically underserved and areas that have some of the best hospitals in the country. So a lot of the challenges that California is facing, in some ways, is the US sort of writ large.

The issue around reopening is California did try to follow the data in terms of a phased reopening. It was one of the earlier states to shut down, and they also reopened with cases declining. What's happened in California, which is different than Florida, in California, the test positive rate has been a stable 6% for the last several weeks. So what that means is California has been able to keep the lid on the pot and keep things from boiling over. It really hasn't had the opportunity to turn the temperature down, because the cases are still increasing. But California is doing a lot of testing — 100,000 tests a day. California is a very, very big state, and that test positive rate translates to a large number of individuals in California.

In Florida, it's the opposite, where the surge in cases has outpaced the rise in tests. I think what has happened is that some states have been content to flatten the curve as opposed to really bend the curve and drive it down to zero. I think part of the challenge as states had reopened was the guidelines were to not proceed with each phase of reopening unless there were two consistent weeks of declining positive cases and test positive rates and an adequate testing infrastructure in place. I think some states have followed that for moving to phase one, but sort of as they moved on to phase two, phase three, that guidance seems to have been ignored.

Davis:

I wanted to ask you what state you thought was doing best so far, but I also kind of wonder if, in a 50-state federal system like ours, if a state really can do that much better job than any other state when the federal government is not perhaps playing the role that some public health experts had wished it were playing in terms of providing the national leadership on supporting the adoption of masks and ramping up PPE production. 

Is it possible for a state to excel if there is lacking federal leadership? Do you see the leadership on the federal level as having played a detrimental role?

Tsai:

I sort of have three answers to that. The short answer is "no." This pandemic has clearly shown the failure of a patchwork response and the result of a vacuum in terms of a national coordinated strategy. We go back to March, with states outbidding each other, trying to get supplies of PPE. Now we're seeing different lag times in terms of testing capacity at different state levels.

So clearly, a coordinated strategy needs to happen. If it can't happen at the federal level for political reasons, then it needs to happen at the state level. So governors need to work together and form interstate compacts and collaboratives to coordinate testing and social distancing policy on the regional level and that also translate down to within a state to coordinate that effort county to county.

The second answer — [an example] of a state that's doing well, it's easy to point to a state that had very low cases and stayed low, but that's not a fair comparison. But we can look at Massachusetts. I'm partial to Massachusetts because I live here, but the state had a very high burden of COVID cases and hospitalizations and fatalities. About two-thirds of our outbreak occurred in patients from nursing homes and assisted living centers. Two-thirds of our fatalities, rather.

But now Massachusetts is testing at a 2% test positive rate, and cases are continuing to go down. Positive rate continues to go down. Hospitalizations continue to go down. So Massachusetts is an example of what a thoughtful, data-driven approach can work, but it takes time. Now, it's been four months to get here, and there are no easy solutions, but people here, despite the 2% test positive rate, are still wearing masks on the street, everywhere you look. So it's a beacon of hope that even in a state that was very severely affected by COVID-19 that good public health can sort lead you out of the wild and get you back into … or sort of lead you off the mountain in terms of the peak of cases is probably a better way of putting it.

The third point is that, now, there's a lack of collective action to deal with the pandemic. Some of the states that did really well are now looking at the southern states and saying, "Well, gosh darn, you guys opened too soon." What we need is the same collective energy that we had in March to flatten the curve, to work together, and to get control of the pandemic.

What I mean is everybody was so focused on New York, appropriately, in March and April, but now we need to take that same energy, because Los Angeles is a new New York. Phoenix is a new New York. Miami is a new New York. We should be making sure that medical volunteers are available in these severely affected areas, that hospitals in these areas now also have PPE or ventilators or field hospitals, that we have adequate testing in some of the southern states that are seeing peaks in cases.

So a lot of that collective energy [is gone]. We were hearing stories about governors shipping ventilators to other states early in March and April. But it seems that collective energy seems to have dissipated. I think this is a time where that needs to sort of come together again.

Davis:

When I talk to experts such as yourself, I hear the same refrain — that we should be "Testing more, tracing more." But we've been saying that for months, and some states more than others have not really decided to ramp up testing and tracing. I just reported on Miami-Dade County, where, back in May, the mayor was talking about hiring 1,000 contact tracers, really ramping up before the storm, and that just never happened. 

Do you think there is the willpower to do that now? Is it too late? What happens if we don't build up that capacity?

Tsai:

I think there is willpower. I don't think it's too late, because Massachusetts and New York looked really grim in March and April, and look at where the states are now. But what needs to happen is two things. One is it's not enough to talk about the number of tests, the number of contact tracers. We actually have to measure how well those processes are performing.

In pre-COVID times, I worked on healthcare quality, and we have a framework of quality called the Donabedian framework around structure, process, and outcomes. So the structural measures are things like the tests, the number of contact tracers, number of beds. The outcomes are cases, fatalities, hospitalizations. But you have to connect the dots and turn the structure, which allows you to have the opportunity to have a strategy, into processes. So what we need are actually key performance indicators of how well our testing is actually working.

We have been part of a large collaborative group, and some of these new metrics are posted on globalepidemics.org. Our website released two dashboards last week, and some of these key performance indicators include the turnaround time for tests, the trace time, the time it takes to perform a contact tracing, because if it takes a week or two weeks to do this, then, mathematically, it becomes very challenging for the contact tracing alone to get ahead of the pandemic growth curve.

We also need to be looking at the percent of cases, positive cases that are actually coming from the contact tracing or targeted surveillance testing efforts, as opposed to just symptomatic individuals, because, again, we've gone backwards. Now some states are only testing symptomatic individuals again.

We need to measure these processes, because if we're not measuring them, if you don't know how long it takes for tests to come back, then you can't figure out the process steps that are needed to improve these. I think every government dashboard, state, federal needs to have these sort of metrics, because it's not enough to say, "We're going to hire 1,000 contact tracers." Did you, and if you did, how many people actually got traced? How many of those actually answered your call? How many people actually gave contacts? How many of those contacts actually got tested? How many of those people who tested positive actually underwent supported isolation? If you can't measure it, you can't improve it.

The second part is that testing by itself, we don't have any new miracle cure, pharmacological or non-pharmacologic, right? The same toolkit that we have now is what we had in March. It worked in March, in April. We were able to flatten the curve back then, but we sort of somehow gave up in May and June.

This is why, as part of our dashboard, we had the county-level COVID risk levels. So counties are grouped into green, yellow, orange, and red based off of their incident number of new cases. So if you have more than 25 per 100,000 cases, that puts you in the red zone, which is the tipping point. That's the point where just the contact tracing strategy alone may not be enough, and you have to enforce universal masking and social distancing. That may even mean a shutdown. It's not meant to be a permanent shutdown, but you may need a shutdown to once again gain control of the infection and flatten the curve.

I've been saying all along that social distancing policy was never meant to be an on/off switch. It was always meant to be a dial that had to be dialed up and dialed down according to the data. However, it seems that the dial is stuck. It only turns in one direction, and politicians are unwilling to dial things back. They're only willing to sort of keep it from moving forward. Clearly, in the states where the pandemic has gotten out of control, a limited shutdown is needed to prevent hospitals from being overrun.

Davis:

I have some pessimistic friends who think that the coronavirus is going to be like the seasonal flu, in the sense that even if we have a vaccine, it's going to mutate. The vaccine will only be so effective, and that this "new normal" is going to be the new normal. What do you think of that?

Tsai:

We don't know how effective the vaccine will be. The vaccine trials are underway currently, so we'll know a lot more in a few more months. So I think it's too early to tell. In the absence of sort of concrete information, I can't think it's a good idea to sort of hope for the best.

But, again, this is not the new normal. We have two normals in the United States currently. In the North, we have a normal where the case counts are very low. We can reopen the economy. People can go back to work, assuming that people are still getting tested adequately, wearing masks, and social distancing. You have another normal in the South, where cases are exploding. So the normal is relative. Normal depends on what the underlying COVID-19 prevalence is, and what's important for people to understand is that you can change that. 

None of this is written in stone. We all can control the trajectory of the pandemic. It's a matter of executing the game plan. We have the game plan. We know what works. We've seen it work in other countries. We've seen it with New York and other states, and now it's just the time to do that. So you can create the normal. It's just which normal are you willing to accept?

Davis:

I don't want to wade into politics too much or make you the target of a presidential tweet, but President Trump, as you have probably seen, claims that we're doing probably the best job of any country in the world. I won't even ask for your opinion on that because I think, objectively, we know that's not true. But I guess if President Trump wanted the United States to truly be the best country in terms of its response to this pandemic, what could or should he do, starting right now?

Tsai:

I think right now, we need to get the public health experts and scientists back front and center, briefing the country on what the data are every single day. Right now, at the highest peak of cases that we've had, it's also been where the federal government has been most absent, where there has been no White House coronavirus task force briefing. So what we need is we need our public health experts like Dr. Fauci and Dr. Birx out there, front and center, explaining to the public what the data means, because if the public understands the severity of the pandemic, they'll understand the level of response that's needed. So I think that getting the information out objectively is incredibly important right now.

Second, there needs to be a coordination of testing on a national level, and that means fixing the supply chain issues. It also means financing not just the supply of tests, but also financing the demand for testing. So that may mean prepaying tests or using the Defense Production Act or a voucher program to make sure that testing is accessible, available, and affordable in the communities where people need them.

I think those two steps would be important steps in the right direction, and convening these sort of interstate compacts or collaboratives so the state governors can work together, because it is going to be very local. We need a national strategy. We need a national resolve. The actual plans are going to look very different, state-to-state, as they should. It's hard to compare Vermont to Arizona right now. So that's why there's a national resolve and support and production of evidence and best practices. But, obviously, the policies will have to be flexible, depending on what the pandemic is telling us.

We have to let the pandemic drive our policymaking. That's the only way to beat the pandemic. Let the data and the underlying growth curve guide our decision making, with the understanding that we can't be reactive. Being reactive is what's gotten us to where we were in March and April, and it's gotten to us where we are now. We have to be proactive in order to beat this.

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