The Opposite of Zebras

Will we ever get over the coronavirus without standardization?

Doctors learn about the dangers of “zebras” early in their medical training. The term refers to an uncommon disease, the sort that everyone knows about but rarely sees in practice. It’s critical for doctors to keep potential zebras in mind. After all, a specific set of symptoms may not be what they first appear to be.

However, the opposite lesson is also important to keep in mind. That is, that when all signs point to something, it almost always is exactly that. This is especially true when it comes to COVID-19.

For decades now, the medical profession has adopted standardization in order to reduce variability. The landmark Institute of Medicine report, To Err is Human, released over 20 years ago, provided an acute perspective on the critical nature of these two objectives in improving outcomes. Atul Gawande captured similar notions in several pieces, including What Big Medicine Can Learn from the Cheesecake Factory, exposing how variability within the healthcare system is both undesirable, and in most cases, detrimental.

Enter COVID-19. The past several months have thrown this construct into disarray. Our knowledge of the virus, and our immune system’s response to it, remains scant. Answers to the questions about how COVID-19 spreads, how to treat it, and how long it lasts among others, are elusive. And yet, rather than heighten our focus on the rudiments of what we do know and learn every day from data and research around the globe, we destabilize our clinical foundations by throwing even more variability into the mix. State and local-driven mandates around social distancing, wearing masks, and even backyard barbeques are varied, confusing, and disjointed.

We find ourselves at a critical point in this COVID-19 journey: proceed as we have been, or make an effort to standardize our response in order to get it under control? We don’t know what happens next, but it may be time to get back to the lessons we have learned over many decades, not only in medicine in general, but in infectious disease and public health. Without doing so, we may continually be playing catch up instead of gaining control.

Take, for example, the missteps in our history. In September 1918, Dr. Wimer Krusen, the public health director in the city of Philadelphia, assured citizens that they were safe from a virus that could spread quickly among people and cause sickness and death. By nearly all accounts, Dr. Krusen is vilified for his inaction and poor decision making. Indeed, one of his biggest mistakes is that he allowed the local Liberty Loan parade to occur. In the six weeks following the parade, 12,000 residents of Philadelphia died from what later came to be known as the Spanish Flu. Despite this, and many other outbreaks, public officials continued to downplay the virus and avoided shutting down cities and activities. The Spanish Flu killed 675,000 Americans and the similarities between it and COVID-19 are striking: lack of public official leadership, high variation among cities and states, and a continual downplaying of the overall risk to society.

We’re making the same mistakes now. Just recently, at least 26 states in the US were experiencing rising cases of COVID-19, with concomitant increases in hospitalizations and now death rates. We know that not wearing masks in public, whether one is symptomatic or not, exposes others to COVID-19 and can lead to deleterious consequences. It is estimated that mask mandates in 15 states may have already prevented more than 450,000 cases of COVID-19. However, guidance to wear masks has been inconsistent at the state and local level, and only mandated in certain cases at specific times. The act of wearing a mask has become political and contentious.

But we’ve seen this before. Secondhand smoking initiatives at first resulted in social upheaval but ultimately had positive effects. In 2006, the Attorney General stated that there is no level of risk-free exposure to secondhand smoke. Between 2000–2015, 27 states enacted smoke-free settings such as bars and restaurants, protecting nearly 50% of the population in the United States. The health effects of secondhand smoke are numerous and well documented.

Vaccines and immunizations offer another use case for standardization. There is a clear link between states that have exemptions for parents to avoid vaccination and disease outbreak. Children with vaccine exemptions have a substantially greater risk for acquiring measles than fully vaccinated children — in one study the risk was 35 times that of the vaccinated population.

In late March, Ed Yong wrote in The Atlantic that controlling the pandemic in the US may ultimately turn into a game of “whack-a-mole,” in which focus and attention is limited to reactionary commitments by those states most directly affected. With multiple schools reopening and interstate travel continuing, it seems highly unlikely that America will gain any sort of control over the spread of the virus in the near future. Instead, we’ll not only be playing a game of whack-a-mole, but we’ll be further threatening any potential economic revival and the health of millions of individuals around the country.

If we can muster the energy and focus to standardize our response across the country, we may be able to return to jobs, revive the economy, and limit controllable morbidity and mortality. To do so, we need to enact specific steps in every state.

First, we must wear masks. There is no doubt that there has been tremendous confusion over masks since the outset of this pandemic, which was not helped by conflicted messaging from public officials, lack of supplies and scarce guidance. Even where mask-wearing is enacted and enforced, reaction to it has led to senseless acts of violence that reflect both a deep-seated xenophobia cheered on by our president, and a misplaced sense of weakness.

Second, we need testing at mass scale and in a uniform and reliable manner, which includes reporting. Increasing testing for COVID-19 has been an uphill battle that started with the CDC’s failure to produce a solid testing kit and then with limited supplies, and delayed results, among others. This includes the president himself making statements to stop testing. Poor state reporting is an additional barrier. Multiple countries have demonstrated the positive effects of population testing and tracking. And yet we still have difficulty providing it, even when people want it. Studies point to other methods, like temperature checks, as being far inferior to testing in tracking the infected.

Third, we must continue social distancing. Similar to wearing masks, social distancing plays a critical role in controlling the spread of the disease. Just as important, it provides a blueprint for reopening our offices and economy.

And that is what is most perplexing of all about the current state of affairs. The country as a whole yearns to return to normalcy, get jobs back, and restart our economy. And yet, the very steps to get us there and keep us safe are being shunned, mocked, halted, or simply abandoned now as state and local measures override them or individuals abandon adherence to them. The whack-a-mole game is in full display.

But here we are now, so what can we do? It starts with changing the narrative. What if, for example, we changed the narrative so enforcement became easier and decisions became bipartisan? Could we position masks as a necessary step to return to work for millions of Americans? What if businesses provided discounts to those who wore masks?

National testing models are already well proven and cut across both state and political lines. But we’ll need additional support and measures to foster expansion and increase capacity in order to succeed. That means consistent and strong messaging, acceptance on the state and local levels, and proper reporting (including race and ethnicity).

We must adhere to these steps. They won’t rid us of the virus nor completely control its course, but at a minimum they will provide a common ground from which to continue the fight by imposing additional boundaries.

Standardization has played a major role in my career as a physician. As Gawande points out, reducing variability does not preclude individuality, and does not disavow zebras or threaten our ability to recognize and combat them. To the contrary, it may embolden us to implement state and local-specific mandates that further the response, based on unique circumstances or challenges.

“Join, or Die” is a political cartoon attributed to Benjamin Franklin regarding the splintered nature of the American Colonies. So too now we face a dire situation and a common enemy. As with all infectious diseases, COVID-19 does not know where state boundaries end and new restrictions begin. It is incumbent on us to stay ahead of its spread and curtail it in the best ways we know how: by melding the pieces of evidence we have together and creating standards around them.

Author: Doug Elwood, MD, MBA, is Chief Medical Officer of PWNHealth
Acknowledgments: Contributions to this article were provided from Doria Weiss and Gabe Gaviola

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At PWNHealth, our mission is to enable safe and easy access to diagnostic testing.

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At PWNHealth, our mission is to enable safe and easy access to diagnostic testing.