Dr. Joshua Sharfstein, Vice Dean for Public Health Practice and Community Engagement at the Johns Hopkins Bloomberg School of Public Health, answered questions for hundreds of local government practitioners in a March 23 webinar about COVID-19 and what cities and other localities should be thinking about as the United States works to control the pandemic. Below is a transcript of the conversation (lightly edited and sorted by category).

Watch the full webinar and view the slides here.


Policy actions cities can take

What policies can cities put into place to mitigate impacts on community members, particularly those who experience inequities, such as low income families, workers who are laid off, etc.?

We’re seeing a lot of interesting things cities are doing … For example, stopping evictions; with the state, getting unemployment going faster; in some cases, food distribution. So I think mitigating the impact of this economic downturn and social distancing is just a critical component for the city.

There’s also just the inequity in that people who are low income for example may be living more crowded, and may be more at higher risk from catching it or passing it on to someone who’s living at home. The way they dealt with that in South Korea and China is they let people, at a minimum (or in some cases forced people to) leave home if they were positive so they didn’t put their family at risk, and I think that’s something cities should be considering too.

Here, cities play a critical advocacy role. There’s obviously a lot of money being talked about at the federal level that’ll come down either directly or through states.

There’s certain things cities can do like not turning off the electricity, not having people evicted, all these things are good to do. But I also think the advocacy role with respect to policy, because obviously a lot of money has got to be made available for this to be successful.

What actions should people take to assist populations experiencing homelessness [or those who are incarcerated]?

With both homelessness and jails you’ve got congregate living, you’ve got a whole bunch of often higher risk people either because of their age or diseases they may have. So it’s potentially quite a powder keg for infection.

I know that some cities are essentially trying to, first of all on jail side, letting people out who don’t need to be there, letting people out who can safely be on outside, particularly people who are much older and really don’t pose a risk, as well as not arrest people for certain crimes that are minor and may be less likely to happen if more social distancing.

The other side, on homeless shelters, I know there are some places that have basically set up tents for people so they’re in their own space outside rather than crowded into a shelter. Others put people who are homeless in hotels or other living arrangements which is even better.

Those things really matter. Even though in the past there may not have been such wide public support for providing that kind of housing, in this case that kind of housing is what’s needed to prevent a run on the ventilators in the county or the city. People should really understand that helping people who are homeless is an investment in everybody’s health.

What are your thoughts on shutting down transit systems to minimize public contact?

Like many things, you’ve got benefits and risks. Transit systems are really important for people to get to jobs. And some of those jobs are in hospitals. So I think you’d be more likely to see systems where they don’t shut down transit but they really limit who can ride to people who have a designated purpose. 

Do you have examples of data other than the American Community Data survey that can be used to identify high risk populations and direct resources accordingly?

There are a lot of databases that can be used to identify populations at high risk. In Baltimore, they have a list of all the people who have special healthcare needs who need support during an emergency like a snowstorm, so that’s a good list to start with. There may be lists of people who use senior facilities or live in senior housing. So I think you have to be creative. Really, you could try to get to the identifiable level if you have the right databases to look at.

There is some discussion about communities of color having less access to screening. Do you have any thoughts on how to alleviate this disparity?

Unfortunately, we have an inequitable healthcare system at baseline. So to the extent to which we’re relying on the healthcare system to provide testing and care, it’s going to be inequitable.

There’s a real good argument why that’s a particularly bad thing in this situation. Each one of our safety depends on not having too many sick patients in the community, because too many sick patients flood the healthcare system. So each of us matters the same for that. So you can have a situation where only certain people get tests, but if the other people get the disease in the hospital, that could sink the hospital system for everyone.

So it’s really important for people to realize that just building this as a clinical response with the inequitable healthcare system that we have really is not going to protect the community or protect anyone in the community. Testing is not treatment. So [there could be] someone who gets a test in a VIP suite, but still gets sick and needs ventilator. If all those ventilators are taken by other people, that’s terrible for everyone.

So I think that what cities can do, working with their public health departments and healthcare systems, is do their best to develop a rational way of making sure that whatever quantity of tests are available are used in the service of reducing the overall spread. That generally means: Priority 1: the sickest patients. Priority 2: healthcare workers. Priority 3: moderately sick patients. People with no symptoms are not on that list. And you could figure out a way, probably with the public health authority, to basically restrict testing. That’s pretty much what Maryland did in an order the Secretary of Health signed today.

Social distancing

Can you speak to the timing of enacting a shelter-in-place policy – not doing it too late to have negative public health impacts, and also not too soon?

In general, epidemiologists think that as an infection is reaching an area, that’s when [a shelter-in-place policy is] going to have biggest impact in keeping things cooled down. The less that’s there when you start, the longer that social distancing policy will work and the more effective it will be. It’s pretty clear that Italy started social distancing way too late. I mean, they locked down the country and they’re still just getting hammered with cases, it had spread so far.

Something to understand about the novel coronavirus is that when you see however it is now, it is kind of the peak of a wave that’s going to hit you. Any one case can pass it on to a bunch of people, but then it takes about six days for that person to develop symptoms, and then a little bit longer for them to realize they’re that sick, and then a little bit longer for them to really need hospital care. Wherever you are now, you’re just seeing the leading edge. So once you start to pick up a couple cases, you know it’s there. If you’re not going then, may be too late.

Some places may just do it earlier just because they know it’s coming. I think the business community may object under any circumstance. This is obviously a brutal decision that has to be made. The challenge that everybody’s facing is that the peak of this could be so catastrophic that it will severely put the community at risk.

Do you have thoughts on how cities can support mental health at this time? What are the effects of prolonged social distancing on mental health and how can we mitigate those?

It’s just physical distance, not emotional distance. It’s really important for people to call and Skype and Zoom and FaceTime with other people, and establish a new normal of social communication so you don’t feel lonely. That’s important.

It’s also important to check on people and see how they’re doing. Last night I talked to a councilman here in Baltimore who had actually mobilized a therapist network. They were having volunteers call people throughout the community, checking in on them and referring to volunteer therapists to talk to people. 

What’s the basis for the idea that this is so much more lethal than the seasonal flu, given the current gap in testing?

The basis is really the case fatality rate, so once cases are identified. It’s not necessarily the infection fatality rate, but the case fatality rate is so much higher. 

The question is, what if you looked at the denominator and more people have the infection, bringing the case fatality rate down. But among people that are cases, 20% need to go to the hospital, about half of them need to be in the intensive care unit. And given that so many people are susceptible, there’s just such a concern about having an enormous surge of patients.

But I think the best evidence is if you take a step back and look at the population mortality we’re seeing in Italy right now. This is well beyond a flu season. This is not an artifact of testing or not testing or anything else. Anybody who thinks this is just the seasonal flu should just read five articles about what’s going on in Italy. That does not happen during the seasonal flu and it’s still just horribly bad there. It’s really a disaster that we need to try to avoid.

Once people have virus and recover, are they immune?

People don’t know that for sure, but people who study viruses believe there will be a good deal of immunity as there is for most viruses like this. There are some case reports of people who have gotten it twice, though it’s not clear whether that was a misunderstanding of the testing or not. In general, I think there are a few converging lines of evidence that suggest people will probably have some degree of protection. But that’s something that has to be checked before you can be sure of that.

Is the summer and warm weather going to slow down the virus? 

Everybody wants that. I put that to Dr. Andrew Peckosz, a virologist and professor at the Bloomberg School of Public Health. He said that we can hope for that, but we shouldn’t expect it. It’s not necessarily true for coronaviruses. There are some warm places where this is actually being spread right now. 

Both these last two questions illustrate an important point. What’s frustrating now is not only the scale of the restrictions, but the uncertainty on so many different topics. We feel like we’re floating in uncertainty. We will have more certainty. We will know the answers to a bunch of these questions, even in the next few weeks. Now, what we learn, it may not all be good news. It may mean that we have to do a longer period of social distancing. But it won’t be that we’re left with all these questions. We’re not stuck in the same place forever, we’re just in a difficult spot because there’s so much uncertainty and we’re worried about having an overwhelmed healthcare system.

How can cities persuade residents to take this virus seriously and steer them away from the idea that it is a hoax or overblown?

People bring all sorts of things, including movies they’ve seen, to the task of assessing a public health situation. If this were neurosurgery, I don’t think people would be saying ‘you really should do the incision here and not here’ – they would be listening to the neurosurgeons. But because it seems like something more intuitively easy to grasp, people have all kinds of ideas, some of which are true or not. 

There are a few ways to counter that. But the best way I would advocate for is not to do it by yourself, not just have the city there saying “please, it’s serious, trust us.” You should have the hospital, the ER, the doctor who goes on TV, whatever the sources of credible information are for people. Bipartisan is best. You just need to find the allies to get the message out and ideally have a credible scientist there who can address all the various questions. 

This is such a serious threat, it’s really for me a once in a lifetime threat. It’s really incumbent on everyone to really fight that, because when people go out and ignore it, it puts everyone at risk.

I’ve seen reports that this could last up to 18 months in waves. Would you anticipate social distancing continue throughout that timeline? And how does that impact people and what should cities be thinking long-term?

Most people think that we’re probably looking at at least a few months of serious social distancing. Then we’re going to have to see where we are. Then you basically can very carefully lighten it up, if you have good testing and tracking and tracing to jump on any small outbreaks. That’s  basically what they’re doing in Asia right now. So that would be one of the best case scenarios.

Of course, if we find effective treatment along the way, or effective interventions along the way, that could make this a lot easier.

When you look out 18 months, it’s super hard to predict. If there really were no treatment, this could conceivably become seasonal, though it probably wouldn’t be nearly as bad as the first year. I think most people in this field think that first year, with a completely susceptible population [is the worst]. If everybody is susceptible, then the virus can have a field day. If a lot of people are immune because they got it last year, the virus doesn’t move as quickly and doesn’t hurt was many people.

Next steps

Beyond the next two weeks of social distancing: what are the next key decisions to be made in April, and how should cities be thinking about a potential second wave? What action can be taken, what should we be thinking about?

So, we’re really going to have to assess where things are every week. Right now we’re on exponential part of growth curve, and that’s not a great position to be in. If we continue to be, there may need to be even tighter restrictions in different places, until we can really try to stave it off and get yourself some time.. Right now the biggest reason for time is for the PPE for the healthcare workers, to get them as much as possible for more patients to be coming in.

But I think the other thing to do is to try to make as much use of the time as you get from severe social distancing to accomplish other things. If you don’t have a good system in place for long term care and nursing homes, this is a good time to do that. So you want to think, how are you going to use those two weeks. Not just waiting the two weeks and seeing what happens. 

I’ll be candid, I think there are a lot of epidemiologists who think that this kind of intense social distancing is going to have to last for a few months to really give enough of a breather to be able to mount a stronger response to the virus. I don’t think, if you’re taking a poll of epidemiologists, [that] there’s a lot of excitement like we’ll just be back to normal in two weeks. I really don’t think that’s the case at all.

Now, could we be helped out by the weather, for example? It’s possible, but people are basically saying don’t count on it. We’re just going to have to see what happens.

And could it come back in the fall? It could, it depends on how far it penetrates now. I mean, a city that gets wiped out now is going to be less likely to have a big problem in the fall. If we’re able to put it off, the goal is that we’re better prepared. Maybe there’s some treatments that have been shown to work. Maybe we’ve got more PPE. And so we’re ready for it, a lot more than we are right now.

Can you share examples of successful policies for social and economic recovery in the wake of a past public health crisis?

That’s a perfectly fair question. You probably have guessed from my answers so far, I’m not in the recovery mindset yet. I do think it’s important for cities though to have a little, teeny bit of their thinking going forward. 

This really is bigger than any public health crisis we’re talking about. This is more like the Marshall Plan. I think it obviously will depend on where we wind up. If we get lucky and miss the brunt of this, it may just be helping to pay peoples’ bills for a while until things start up again. But if there’s a lot of people dying that’s going to be an extended period of time, and I think that’s unprecedented in modern history and we’re going to have to come up with new mechanisms to jumpstart the economy and give people the chance to rebuild their businesses.