Oregon was one of the first states to document community spread of the coronavirus — meaning that patients who got sick with COVID-19 illness had been going about their daily lives, without a connection to anyone known to be infected or at high risk due to travel abroad.
Yet as the virus has spread, Oregon’s approach to the disease has been a quite different from that of neighboring Washington state, which has led the nation in deaths from the illness. On Wednesday, Rolling Stone spoke with Dr. Richard Leman — a public health physician and Chief Medical Officer, Health Security, Preparedness and Response for the state of Oregon — to talk about why the approaches to mitigating the spread of the coronavirus will not be the same nationwide.
Rolling Stone: Help me understand the differences I’m seeing. Seattle has entered a lockdown phase — big businesses have shut down offices, and schools are closed for six weeks. But Portland, a few hours to the south, seems to be taking a less dramatic approach to the virus. The outbreak is more severe in Washington, but how does that work from a public health perspective? The two metro areas, communicate with each other — in terms of people in car traffic, train traffic and plane traffic. Are differentiated responses like this part of what we should be expecting to see as the coronavirus crisis plays out?
Richard Leman: If we look overseas as well, you see different approaches. A lot of folks have definitely been very, very aggressive, and kind of thrown everything but the kitchen sink — and maybe even the kitchen sink as well — at this. Our goal is not to be flashy, our goal is to try to do what works.
So what are the key tactics that you’re emphasizing to fight the spread?
We are working with the entire population to get to a point where we are all on the same page. We are all working together to stay home if we’re sick. Because that’s when we think that the most transmission occurs — when someone is actually coughing and broadcasting virus. We are trying to make sure that, in school settings, people do stay home if they’re sick whether they be students or faculty or staff. If you’re sick, you don’t go to school in the first place. [Editor’s note: When he spoke to Rolling Stone Leman was recommending against school closures; under pressure from teachers and parents, Oregon Governor Kate Brown announced a two week school closure beginning next week.] Don’t go to workplaces if you’re ill. And if you do get sick while you’re there, you withdraw immediately and you go home.
Also we are making sure that people are staying a little further apart from each other than they usually do. This is the social distancing side of things. That’s part of mitigation, as they call it, in order to slow spread and in some cases prevent spread. If you’re around somebody and they’re coughing, you stay farther away from them. In general, if we stay farther away from people than we usually would — it may not feel comfortable initially — but it’s an effective strategy to limit spread.
Help me through the thinking on containment versus mitigation. It seems like we’re past trying to shut down the spread of the virus totally. So is the goal to keep the throughput of patients at a manageable pace so that the health system doesn’t get overwhelmed?
That’s the basic idea behind mitigation. And it applies not only in the healthcare setting, but for society in general. If you have fewer people who are ill at any given time — even if the total number of folks who become ill ends up being the same — it’s just a much more manageable situation.
I realize those are kind of jargony terms. But containment is when, either you have no cases in your community and you’re trying to prevent any, or you have, say, one case and you are trying to prevent that from leading to any other cases. That’s maybe oversimplifying, but those are examples.
Mitigation is finding ways to make it so that the spread of illness is not as quick. So we can slow that process. And if we do that, that’s important. For the healthcare system, that’s important for society at large, it’s easier for businesses to continue to do their functioning. It’s easier for communities when not everybody is sick at the same time.
So that is our goal. Our goal is to do the things that are effective in order to slow the spread. And because people appear to be definitely most infectious when they are actively symptomatic and coughing, we just need to make that an understood part of the culture: We are going to isolate ourselves during times that we are sick.
What should people do if they get sick?
If people are sick, but they’re not that sick, they’re basically feeling okay even though they’re ill. Those people do not necessarily have to go to see a healthcare provider. They don’t necessarily have to go to their clinic to be seen. And they certainly don’t need to go into the emergency room if they’re basically feeling alright — just to get tested. We need to avoid overwhelming our emergency rooms with people who don’t need to be there.
If somebody is sick enough that they do need to be seen by a healthcare provider, we want them to — if they’re going in to get seen — then they need to let the healthcare provider know so that steps can be taken to prevent exposure to other people in the healthcare setting.
I think communicating this conceptual shift is important. The idea for now is not to eliminate all cases of the virus to have that go away to zero. It’s to keep this spreading at a manageable rate so that the people who need the most care can get it in and have the best shot at surviving this?
For the time being. I think that that is the right approach. And we will get to a point where either this falls to a low level because people’s immune systems have seen this and so we will not see as much illness from this. Also, if we can get it down to smaller numbers of people, then the types of contact investigation around people who are ill, that may help slow things even more and stop transmission. That’s what happened during SARS. But we’re not in that position right now. We don’t know everybody who is ill. There is transmission in the community. So while contact investigation can be helpful in limiting spread, it’s not gonna stop it at this point. When we no longer have broad community transmission, then contact investigation may be very helpful and effective in stopping the outbreak.
Define community transmission.
In Oregon, we don’t have huge numbers of people affected, but there are people where we have no obvious connection either in terms of travel from an area where illness is known to be circulating in a high level and we don’t have any known contact with a person who is ill. So we do have transmission going on in the community.
I understand the state was in danger of running out of tests as recently as Wednesday. Are you confident that there are now enough tests to keep up with the simple diagnosis and then can get into some of the investigative work?
Actually the problem was not with test kits. It was with another of the things that we need in order to be able to do polymerase chain reaction testing [that looks for genetic markers of the virus], in my understanding. So our problem was not the number of test kits, with the specific stuff that you need to do the COVID-19 testing. It was with another product that we just had a little trouble getting enough of — but now that problem is resolved. So we are up and running. We are using that testing at the public health lab in order to figure out where in Oregon there is actual evidence of illness because it’s probably not everywhere. And we can use that testing in order to figure out what is the geographic distribution.
Once we get to a point where there is a broad community transmission, I don’t think that testing is going to be as important. The key thing is going to be if people have fever, if people have cough, if people have sore throat, then we just need to assume they have something, and that something could be COVID-19. So we want them, whether they are sick enough to go in to get seen or not, we want them to self isolate. We don’t want them going into work while they’re sick. We don’t want them going to school while they’re sick. We don’t want them going to a long term care facility or exposing our elders while they’re sick. That’s just part of what we all need to do together in order to address this and slow the spread.
Why does social distancing work against coronavirus?
This does not appear to spread by an aerosol, a fine mist that hangs in the air and spreads all over the place, the way measles does. This is spread by heavy droplets. They can get coughed out when somebody’s sick, those fall out of the air, typically within three feet and almost always within six feet. And so if we can prevent close contact with somebody who is actively ill, we think we’ve done a lot in terms of limiting spread of this disease. Not everybody’s going to be able to stay six feet away all the time, but that would be a pretty effective measure in terms of limiting the likelihood of exposure. And that’s particularly important if somebody’s sick, if somebody’s sick, you stay farther away from them, you don’t get coughed on.
We live in a free society, some folks are not getting the message that this is serious. What else should we do to counteract those who are not responsible?
If people are out in a public area where there might’ve been somebody who was sick, if they wash their hands regularly or if they use an alcohol-based hand sanitizer in order to kill any virus on their hands before they touch their face or their eyes, that’s also useful. Alcohol based hand sanitizer is effective in killing this virus. And also cleaning frequently touched surfaces is useful. If somebody coughs on their hand and then touches the door handle, if we can clean those door handles off periodically, we can also limit spread that way.
What do you think about air travel or people on public transportation — these are confined spaces where passengers are unable to control the social distancing aspect?
If you’re sitting within six feet of somebody, like if you’re on an airplane, who you need to be worried about is the person next to you, or maybe the person right behind you, and whether they are coughing. But you know, there is risk in everything that we do. And so I don’t think we’re telling people, you know, we need to shut down the airlines necessarily. But people do need to be cautious. Ideally people will be screening to figure out whether somebody is sick — and ideally that person should not be getting on the flight. That would be the first step. It’s always possible that somebody could get sick while they’re on the plane. And in that case it would be good if people have masks available that can be given to that person — because that actually helps you to capture the droplets so that they don’t get spewed out everywhere.
I’m trying to get a handle on what’s universal advice versus what’s location by location advice. New York is different in density and risk than Portland, which is different from Iowa City. To what extent should people go around their daily lives with some sensible precautions until they hear otherwise from local authorities.
The folks that we really want to try to protect are the people who are at the highest risk from this. Making sure that we protect people in long-term care facilities where we have larger numbers of folks who are older. I already told my mom, and we will be telling other people that, you know, if you’re a bit older, then maybe it’s just as well not to go to a big gathering where there’s the potential that you could get exposed. Also putting up a sign that just says, “If you’re sick. please don’t come in right now.”
We all need to take this seriously. It does make a difference if you wash your hands regularly or use hand sanitizer — that makes a difference. If you are a person who’s ill, if you stay home and you don’t expose other people at work or at a large gathering, that makes a difference. If public health can work with people and provide them with the information so that they know what symptoms they need to watch for, and when they need to start self isolating, and for how long, that can make a difference.
If people can, in their workplaces, figure out how not to have large meetings where everybody’s crammed into a single room, and people look into whether they can do some of the work by telecommuting, that can make a difference. We’ve got a number of tools that can be effective. We just need to use them, take this seriously and use them. And that can actually slow the spread of it.
Is there any epidemiological modeling that shows how long we are going to require this change in practice? How long are we expecting our lives to be disrupted?
We need to be prepared to do this for months. And we sometimes will see a second wave of illness and we need to be prepared for that. We’ll be watching for that. So we are in this for months. I don’t know that we’re talking a full year. I can’t promise you that it won’t be — depending on whether we see a second resurgence. But I think we need to be prepared to do that.
Well, that’s sobering. Are there other other messages you want to make sure get out there?
It was admittedly a milder illness, but there were many, many people who got an infection from H1N1 [influenza] back in 2009. Many of the measures that we’re talking about here are measures that were employed then — and it works, it helps to slow the spread of infection. So we’ve done this before and we can do it again. But we need to be able to do it together.