As Massachusetts and most other states head down the path of increasingly stricter social distancing policies and even complete lockdown, many people ask whether all of this is necessary, given the mounting impact on the economy.
The moral argument that stresses our social commitment to protect the elderly and sick might be debated by some. However, lessons from other countries — particularly Italy and Spain — suggest that, if not controlled in a timely manner, the outbreak will kill and harm not only COVID-19 patients but also, indirectly, many other patients as well.
If the outbreak spreads among high-risk patients — older people over 65 and younger people with underlying comorbidities, such as diabetes, hypertension, obesity, and asthma — it is likely to lead to an uncontrolled surge of acutely and critically ill patients who will require extensive hospital care. This surge is likely to overwhelm our hospitals and even compromise their functioning. As a result, hospitals would not be able to provide sufficient care to patients with heart attacks, strokes, or other critical health conditions. This is what we call a hospital crash.
Are we left with the hard choice between long-term lockdown and a collapsing economy or attempting to reopen the economy quickly and crashing entire hospital systems? In fact, does the current policy of social distancing ensure that we can avoid hospital crash scenarios? The right answer to both these questions is: not necessarily.
The key concept we must address is high-risk clusters. These are places like a senior living facility, a ZIP code, or a county that has a dense concentration of high-risk patients. Identifying high-risk clusters and managing the risk they pose is central to avoiding the hospital crash scenarios observed in Italy and Spain.
Senior living facilities — nursing homes, assisted living facilities, and long-term care hospitals — are one particularly salient type of high-risk cluster. In the United States, we have already experienced the devastating consequences of a COVID-19 outbreak within a nursing home. In Seattle, a single 120-bed nursing home was exposed to COVID-19. There we have seen 80 percent of the residents and one-third of the staff infected, over 30 hospitalizations, and 35 fatalities. This is just one site within only two weeks. In Madrid, the epicenter of the COVID-19 outbreak in Spain, more than 20 percent of the nursing homes were affected, causing hundreds of fatalities and hospitalizations.
At the COVID-19 Policy Alliance, led by MIT faculty, we have analyzed and created a risk analytics tool that maps all of these high-risk sites across the nation. Despite this evidence and stricter social distancing policies, many senior living facilities still have employees, suppliers, and vendors coming in and out without testing, sometimes working across multiple facilities, and increasing the chance of an outbreak hitting multiple sites at once. The Centers for Disease Control and Prevention has announced guidelines that encourage elderly communities to design and implement policies to minimize the risk of a COVID-19 outbreak. But such guidelines and suggestions are not enough.
Focused state-level efforts and policies are also needed. Every state should mandate a policy that prevents anyone with unconfirmed or positive COVID-19 status from entering these facilities. At the state, expert teams should be formed to guide, train, and enforce critical practices, such as infection control and isolation as well as testing and screening supported by experts via telehealth leveraging telehealth platforms. As has been made clear by medical professionals across the nation, personal protective equipment, including N95 respirator masks, gloves, gowns, other equipment, and medicines is critical.
The story of Italy highlights a second important type of high-risk cluster. The epicenter of the outbreak in the Lombardy region consists of numerous small villages and towns. The city of Bergamo, with a population of 120,000, has experienced well over 600 fatalities and hundreds of hospitalizations — leading to the crash of strong local hospitals and horrifying images seen around the world from the overwhelmed ICUs. These hospital crashes caused many more fatalities of patients with other conditions who could not receive the care they needed.
Our analysis of the demographics of this area reveals an unusually high proportion of older people, with more than 25 percent of the population over 65 and close to 40 percent of the population over 55. Fortunately, the population in Massachusetts and many other states in the US is not so old, according to the US Census. However, many Americans do have underlying health conditions that make them vulnerable.
Is this a battle that is already lost? Absolutely not. The story of two towns in Lombardy — Codogno and Vò — point us in the right direction. Four weeks of extensive focused testing and social isolation moved these heroic places from being hot spots of COVID-19 cases to zero new infections.
In the United States, there’s more we can and should do to focus on high-risk patients and high-risk clusters. They all require government coordination, intelligence, analytics, technology, and strategies that we currently do not have — but we could. It’s essential we pursue these strategies immediately to avoid choosing between collapsing our economy or our health care system — and the loss of life that would entail.
Simon Johnson and Retsef Levi are cochairs of the COVID-19 Policy Alliance and professors at MIT’s Sloan School of Management.
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