Published May 13th, 2020 at 6:00 AM
It started with a drip. News came from Washington state in late January that the United States had its first confirmed case of COVID-19. Word of the new coronavirus had been filtering out of China for weeks.
A steady stream of warnings at the national and international levels soon followed. Then, in March, came a torrent of school closings and stay-at-home orders.
Suddenly, the pandemic swamped the economy, wiping out more than 20 million jobs and inviting comparisons to the Great Depression.
Now, two months after stopping life as we knew it, local officials are attempting to reverse the flow. Society is gradually reopening throughout the Kansas City metropolitan area.
Is it safe? Are we striking the right balance between public health and economic growth? Will the price we pay for the decisions we make be paid in blood? If so, how much? Is it worth it?
The tradeoffs involved bring to mind a famous quip by Harry Truman about economists: “Give me a one-handed economist,” he said. “All my economists say, ‘On one hand… on the other.’ ”
In the roundabout world that is COVID-19 testing raises almost as many questions as it provides answers.
The urgency of the issue was on full display Tuesday in Washington, D.C.
Anthony S. Fauci, a key member of the White House’s coronavirus task force, urged caution in Tuesday testimony before a U.S. Senate health committee.
“The major message that I wish to convey… is the danger of trying to open the country prematurely,” Fauci told The New York Times prior to his testimony. “This will not only result in needless suffering and death, but would actually set us back on our quest to return to normal.”
Also out of the capital came word, in an unreleased White House coronavirus task force data obtained by NBC News, that Kansas City was listed among “locations to watch” for spiking coronavirus spread.
Testing is at the very core of the “yes… but” nature of the COVID-19 reopening debate.
There are two types of tests for the virus. One uses an oral or nasal swab or saliva to detect an active infection. The other examines the blood for evidence of prior infection.
The Kaiser Family Foundation noted last month “near total agreement” that the United States was not testing enough people to safely relax social distancing measures. The problem, the authors said, was that “there is no agreed upon benchmark for how much testing we need to do to get there.”
Of the five models cited by the foundation, including a few from different Harvard researchers, testing recommendations for the nation as a whole ranged from as low as 1 million to as high as 23 million people per day. That would be the weekly equivalent of anywhere from 2% to 50% of the entire U.S. population.
One estimate, by the COVID Tracking Project, suggests the U.S is a long way from achieving even the lowest benchmark.
Its data suggested the U.S. conducted about 400,000 tests on Monday, less than half of the low-end recommendation of the Kaiser foundation. Even so, that was the highest one-day total since the project began in January, but the figure dipped on Tuesday.
Additional testing will, of course, identify more new cases. The dilemma there is that, even as it allows for a fuller picture of the pandemic’s scope, it risks alarming the public with a steady drumbeat of new cases every day.
The key for public health officials is to make sure “people understand what numbers you are presenting and what they actually mean, rather than allowing interpretations to kind of fly wild,” said Charles Cohlmia, manager of the Communicable Disease Prevention and Public Health Preparedness Division of the Jackson County Health Department.
Part of the context is that public health agencies are expanding their reach into communities by bringing on more “contact tracers.” These workers get in touch with people who might have encountered someone who has tested positive for the coronavirus.
Meanwhile, as scientists and physicians learn more about the virus, the scope of potential symptoms is growing beyond the initial warning signs that included a dry cough and high fever.
Evidence of potential infection now includes sore throat, headache, muscle aches, vomiting and diarrhea, said Dr. Mark Steele, executive chief clinical officer for Truman Medical Centers in Kansas City, Missouri.
Testing got off to a rocky start in the U.S., with complaints about defective kits from the U.S. Centers for Disease Control and Prevention. Labs across the nation also complained about a lack of testing materials, including the swabs and chemicals known as reagents.
Shortages of personal protective equipment (PPE), such as masks and gloves, also hindered testing.
Steele remains concerned about his slim stockpile of PPE. But he, and others, agree that choke points in the testing supply chain have all but vanished.
At the University of Kansas Health System lab, for instance, Rachael Liesman said they are on their way to tripling their capacity to about 1,500 per day. The system is running tests for outside public health agencies in addition to its own patients.
As director of microbiology, Liesman oversees infectious disease testing in the lab. Her situation illustrates another double-edged sword when it comes to testing.
More testing means the need for more manpower, and Liesman anticipates losing the additional staff she poached from other parts of the lab as the hospital gradually reopens along with other businesses.
“We are thinking a lot about, ‘OK, when we lose these people, how are going to staff? How are we going to make this work?’ ”
So, if simply reporting the number of new cases each day is fraught with caveats and potential misconceptions, what is the best way to tell if we are winning the war against the virus?
Here again, the picture is muddled.
The number of deaths could serve as an adequate measuring stick. Diminishing mortality would seem to indicate that the virus is somehow pulling back.
That is, in fact, the indicator Kansas Gov. Laura Kelly and her team are using to manage the phase-in of her reopening plan.
Its current data show an average of about three deaths a day in the span of a couple weeks ending May 6. The figures fluctuate, with a high of six deaths on April 25. (Another metric, hospital admissions, has also bounced around, but has generally trended downward to the six recorded on May 6.)
But death counts can also be misleading. Much is made each day with a death toll in the United States that now exceeds 80,000 people.
But the U.S does not look so bad when its mortality rate is compared to other hard-hit countries.
Data from Johns Hopkins University shows that the U.S. mortality rate of 24.31 per 100,000 population is among the lowest on the list. Only Germany, Iran and Brazil fare better, and given the regimes in the latter two countries, that data could be suspect.
Yet Hopkins warned against conflicting variables, including testing: “With more testing, more people with milder cases are identified. This lowers the case-fatality ratio.”
An older population could also increase the number of deaths, according to the university, as could a poor health care system with overwhelmed hospitals.
On May 5, authorities in Missouri issued their own “analytics update” as part of its reopening plan.
Those metrics included a measurement of the rate of positive results from tests given in the state between early March and early May. The overall positive rate was about 9%, with a spike toward the end of March.
The data also showed that Missouri had a mortality rate approaching 10 deaths per 100,000 population, about middle of the pack for the five other states used for reference points.
So, given all the uncertainties and questions surrounding the COVID-19 measuring sticks, perhaps we are all just like leaves carried along by a stream. The destination is uncertain.
That’s life with the coronavirus, as Liesman acknowledged. “We are seeing our numbers increase on a daily basis, and I expect that to continue,” she said.
“Oh God, I don’t know — forever,” she laughed. “I am honestly not sure. The virus will tell us when.”
Mike Sherry is senior reporter for Kansas City PBS. He can be reached at email@example.com or 816.398.4205.