Crozet Annals of Medicine: Strong Medicine


A deep weariness has settled into my bones. I feel like I am living the plot to the movie Groundhog Day, where every day is a repeat of the day before and nothing changes. It has been six months since the first COVID-19 case was diagnosed in the US and still we do not have a national plan to defeat this thing. I suppose waiting for a vaccine could be considered a plan, but we are going to lose a lot of people in the meantime. 

A thousand people a day are dying in America of this thing, day in and day out. Over 160,000 dead, and counting. By November an estimated 250,000 or more Americans will have died of COVID. 

So, I am tired, tired of the anxiety infecting my workplace, the fear of invisible contagion.

I am tired of the sense of abandonment that reusing disposable PPE engenders. 

I am tired of seeing other countries doing so much better at this than us. With 4% of the world’s population we have almost 25% of the world’s deaths from COVID.

I am tired of leaving work exhausted and grimy only to see people gathering with no masks and no distancing. I don’t like it when people with masks around their chins stand too close to me in the grocery store. At work in the ER I can instruct them in the proper fitting of a mask, but this seems problematic in Harris Teeter. Still, I am tempted. 

I am tired of stripping off my scrubs and shoes on the front porch after work, before I can enter my home. Actually, I am not that tired of it. It is kind of liberating, but I’ll bet the neighbors are getting tired of it. It is hard to remain a health care hero to your neighbors while in your underwear.

I am tired of the endless debate about whether our kids can go back to school. They cannot. They cannot because we could not stay out of bars, parties, and non-essential indoor activities this summer. Some of us refused to wear masks. As a result, case rates are now too high in most areas to open schools and are still rising in 34 states. 

We can fix all of this, but it will take strong medicine. 

The New England Journal of Medicine published some evidence-based guidelines this week for what it would take to get our kids back to school. I thought they were clear-eyed and useful, so I will share them with you. 

1) The safest way to open schools fully is to reduce or eliminate community transmission while ramping up testing and surveillance. 

2) Any region experiencing moderate, high, or increasing levels of community transmission should do everything possible to lower transmission.

3) The path to low transmission in other countries has included adherence to stringent community control measures— including closure of nonessential indoor work and recreational spaces.

4) Such measures, along with universal mask wearing, must be implemented now in the United States if we are to bring case numbers down to safe levels for elementary schools to reopen this fall nationwide.

5) If such measures were adopted now, transmission in many states could probably be reduced to safe levels for mid-September or early-October school reopenings. 

6) Many school districts would be able to open even sooner — although large improvements in testing volume and speed of reporting would be needed to enable appropriate levels of community surveillance.

7) Adults who work in school buildings (or drive school buses) should be provided with PPE

8) Schools’ social and physical infrastructure will also need to be modified. Students and teachers may need to eat lunch in their classrooms, and staff rooms may need to be closed to discourage adult congregation.

Even if schools can make creative short-term use of additional space, thousands of schools—particularly those serving low-income students of color—will require significant federally funded upgrades to improve ventilation, sanitation, nurse’s offices, and hand-washing and bathroom facilities. These improvements have long been needed regardless of Covid-19; they are essential investments in educational equity and opportunity.

But the fundamental argument that children, families, educators, and society deserve to have safe and reliable primary schools should not be controversial. If we all agree on that principle, then it is inexcusable to open nonessential services for adults this summer if it forces students to remain at home even part-time this fall.

So, there you have it. A national plan! My fatigue is lifting already.

Universal mask wearing. 

Two months of lockdown. 

Rapid and widely available testing.

Physically reconfiguring our schools. 

I told you it would take strong medicine. But the sooner we start, the sooner we will fix this. A vaccine is simply not going to save us. We have to save ourselves. 


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