The coronavirus pandemic has taken a dark turn. New cases in the U.S. are topping 80,000 per day, breaking previous records, while more than 40,000 Americans are hospitalized. This comes at the start of the colder months, with people spending more time indoors where the disease spreads more efficiently.

"We are not going to control the pandemic,” White House chief of staff Mark Meadows told CNN on Sunday, suggesting the administration would concentrate on treatment or mitigation. On Monday, President Trump denied that, saying his administration was still aiming to control the virus and suggesting that the nation is “absolutely rounding the corner.”

Conflicting messages out of Washington about COVID-19 are nothing new. For months, state and local governments have charted their own courses, pursuing differing strategies when it comes to economic shutdowns, mask mandates and their overall public health approach.

To make sense of what policymakers should be thinking about at this point, Governing spoke with Amesh Adalja, a senior scholar at the Johns Hopkins University Center for Health Security. Dr. Adalja, who has worked with New York, Pittsburgh and the Federal Emergency Management Agency, specializes in emerging infectious disease and pandemic preparedness. During the pandemic, he has served as an advisor to the NCAA and the International Monetary Fund, among other groups.

An edited transcript of our conversation follows:

We are seeing cases rising rapidly again and now the coronavirus has spread all over the country. How afraid should we be, or what are your main concerns at this point?

Dr. Adalja: We knew there would be increased cases as we moved indoors and people got back to something more like normal life. No place is seeing a decrease in cases; they’re all flat or seeing increases. The question is, do we have the system in place to handle those cases, and in many parts of the country, the answer is no. Many did not build up the public health infrastructure, such as contact tracing, to keep people from being hospitalized. In some places, hospitals are warning that there may be capacity problems in the future, and we’ve already heard about field hospitals in Wisconsin and an auxiliary center in El Paso.

This disease first struck mainly in big cities like New York, Chicago and New Orleans. I’ve been worried all year about rural areas since there have been so many hospital closures,  and now rural areas are the hardest hit. 

I think that rural areas are particularly vulnerable. They might not have the population or crowding, but also they may not have the ICU capacity, or only one hospital for a huge area. (Note: In some cases, patients are being transferred hundreds of miles.) 

Not only do they have restrained bed capacity, they won’t have infectious disease capacity, or critical care capacity. Telemedicine has really risen during this pandemic, so they may have access to specialists, but some rural hospitals only have six ICU beds, or 12 ICU beds, while an academic hospital may have over 100 beds.

 Amesh Adalja, senior scholar at the Johns Hopkins University Center for Health Security. (Photo courtesy Centerforhealthsecurity.org)


Hasn’t treatment gotten better? Aren’t more people who are hospitalized coming out alive?

We’ve definitely gotten better than we were in March. We have tools like Remdesivir, and we’ve learned not to put as many people on ventilators that damage lungs further. All of that together does translate into better outcomes for patients when they’re hospitalized. But we still don’t have a good tool for keeping them out of the hospital.

It seems partly a fault of media coverage that people think there are only two outcomes – you either die or recover, and most people who get COVID-19 don’t die. Yet we now know there are “long COVID” patients, who don’t die but suffer for months. Since it’s a new disease, we don’t know the true long-term effects.

We’ve always known that people who are critically ill with COVID, those people are going to have a long recovery. What we’re seeing now with COVID patients, including some who don’t need hospitalization, is that they’re left with symptoms such as fatigue or difficulty concentrating. We don’t have enough information to predict who will develop these long-haul symptoms and who will not, how long they will last and how debilitating they will be.

This is also part of the reason why it’s wrong to say young people are getting infected and it’s not a big deal. It’s hard to know which of them will end up with long-haul symptoms. Many people are just focused on death but there are symptoms that do impair quality of life.

Sometimes we’ll hear politicians say we need to “listen to science,” but do you think there’s some confusion about what that means, since the science changes? Whenever he’s asked about Tony Fauci, for instance, President Trump says he makes mistakes, that Fauci said people shouldn’t wear masks early in the pandemic.

Science doesn’t come to you from bolts to heaven. It’s not something that’s immutable, the 10 commandments of COVID that are immutable. We learn more about the virus every day. When you’re dealing with a new virus, not known to science before December 2019, there are going to be changes in treatment, and that’s normal.

You shouldn’t think that all of a sudden, as soon as this virus was discovered, everything known about it was downloaded into scientists’ minds and wasn’t going to change, based on new cases and treatment. In anything with science, you learn and integrate it with what you know.

To say that people had different positions in March, that’s like ridiculing Einstein because he changed what we knew about physics since Newton.

Public health is highly decentralized in this country, with the CDC typically issuing guidelines that are carried out by state and local health departments. Do you think the U.S. suffered for not having more of a national strategy, like other nations?

I think that we have a good system. If you look at what CDC did during Zika, Ebola, the H1N1 flu, that worked well. It’s the premier health agency in the world.

They have been put in the back seat since February. They couldn’t speak directly to the public. Their guidelines were vetted not for the science and the epidemiology, but how they coordinated with the president’s whims at any moment.

It’s fair to say that the administration has sometimes undercut its own messages. State and local governments have certainly gone in different directions in terms of their approaches to health and their desire to seek balance with things like the economy. With COVID-19 spreading fast, what should governors and mayors do as we head deeper into the fall and winter?

What they should be doing is trying to understand what’s driving threats in the area they’re governing, whether it’s a state or city or borough or whatever it might be, and then having a targeted intervention that fits, such as a mask mandate.

We know the answer to this pandemic is three simple words: testing, tracing and isolating. It’s very difficult for a mayor of a small city to come up with a testing strategy, but we’ve seen governors step into the void left by the lack of a national testing strategy.