By Eli M. Cahan
With each passing day, the number of cases of coronavirus disease 2019 (COVID-19) continues to rise. As of this writing, more than 240,000 patients worldwide have been confirmed for the disease, including over 13,600 across 50 states in the United States.
These figures almost certainly underestimate the burden of disease in the U.S. Diagnostic test shortages and restrictive testing protocols have led to confirmation almost entirely of severe cases, implying many more subclinical, asymptomatic and mild cases likely exist below the surface.
Non-pharmaceutical interventions are critical to defeat infectious pandemics
To prevent further proliferation and dissemination of this unseen enemy, the U.S. has begun to follow the lead of other countries (such as Taiwan, Hong Kong, Singapore, China, Italy, Spain and France) to enact various non-pharmaceutical interventions (NPIs) as initial countermeasures.
Chief among these are social distancing (involving limitation of group gatherings); workplace modifications (including eliminating non-essential meetings); hygiene practices (including rigorous hand-washing protocols); school suspensions (including shifting to virtual classes); changes to housing (including temporary evacuations); and quarantine (including travel restrictions, self-isolation and regional lockdowns).
NPIs can be immensely disruptive to daily life: in the most extreme cases, putting lives on indefinite hold, as they have for 780 million in China, 60 million in Italy and 47 million in Spain. Given how rudely NPIs interrupt the routines of an interconnected civilization that is wealthier and healthier than at any point in human history, pushback is natural.
This is especially predictable coming from high-achieving, seemingly invincible young people: like at the University of Delaware during H1N1 flu outbreaks in 2009, where nearly half the student body ignored social-distancing measures. Recently, petitions against NPIs for COVID-19 have also begun to rear their heads at Stanford.
However, as disruptive as they may be, NPIs are instrumental to “flatten the curve” of clinically-relevant infections, so national healthcare systems have sufficient capacity to provide the urgent care required by these patients. Moreover, NPIs are particularly important when few effective pharmacologic interventions exist (such as antivirals or vaccines) — as is currently the case. And local communities are crucial drivers of whether NPIs are effective, depending whether they implement them comprehensively in a unified manner — or not.
Stanford has led the adoption of non-pharmaceutical interventions nationally
In the current COVID-19 outbreak, university communities have been vital early adopters of NPIs. Stanford (along with Harvard and MIT) has been a leader in this regard, as President Marc Tessier-Lavigne and colleagues described in The New York Times on Tuesday.
The comprehensive actions taken by Stanford began on Feb. 27 with suspension of study abroad in Florence and culminated on March 13 with requiring that undergraduates evacuate campus housing. In between, the University issued travel restrictions, digitized all classes for the conclusion of winter and beginning of spring quarter, and canceled athletics as well as non-essential research.
Stanford has been a catalytic force for good by setting this precedent. Following California’s March 16 shelter-in-place order, Stanford has provided leadership on how large organizations can adapt to this new normal: including rapid uptake of telecommuting and commitment to continued staff pay/benefits. And amid these life-altering and unprecedented changes, the Stanford community has been a shining beacon for how diverse groups can unify in solidarity and support.
Petitions against non-pharmaceutical interventions endanger our community
This is why I was so disheartened to come across one petition in particular seeking to change Stanford’s NPI policies. The petition is certainly well-intentioned, seeking “to protect the entire Stanford community … and reduce the panic among all members living on campus.” So far, over 400 campus residents have signed it.
The petition firstly calls for additional information on best preventive practices and clarifying facts susceptible to misinformation. These requests are consummately reasonable.
The petition secondly requests transparency into University decision-making efforts and the public identification of suspected or confirmed cases. This second set of elements is understandable if impractical, unfeasible and/or unethical. Complete transparency, while idealistic, is commonly suspended during health emergencies to expedite protection of public health. Likewise, public identification of cases is unethical under health privacy laws such as HIPAA.
The petition thirdly includes calls for more drastic changes to NPIs, including “separat[ing] self-quarantine spaces for confirmed and suspect [sic] … [and] preventive purposes” to “centralized facilities separate from ordinary student living quarters.” This set of requests is significantly less acceptable.
Indeed, these demands are flawed, myopic and potentially illegal.
They are flawed given that self-quarantine is amongst the safest measures individuals can take to reduce their chances of propagating an infection throughout the community. Since the virus responsible for COVID-19 is not stable in aerosol form for more than a short duration, it is unlikely that individuals conducting self-isolation can infect others in their housing facility. As shared surfaces are being sterilized multiple times daily, the probability that healthy students would come in contact with sufficiently high-density viral titers to cause infection is low.
These demands are also myopic given that, as the authors of the petition correctly describe, there is rising suspicion that subclinical, asymptomatic and mild COVID-19 cases are driving the pandemic. Since the young are more likely to represent these “stealth cases,” it is possible that, with the imminent expansion of diagnostic testing, many more such cases will be confirmed — and require quarantine. This will quickly overwhelm the capacity of any centralized facilities: especially if the University were to “plac[e] only one student on each floor” of these centralized facilities. In this situation — and given projections that between 50-65% of Americans will become infected over the epidemic course — shared housing would be flooded with “late” cases. Geographic clustering of “late” cases during their most infectious window (rather than spreading caseloads evenly over time) would amplify the risks to uninfected residents remaining in shared housing at that time.
Additionally, these demands may be illegal, given that the “large isolated spaces not currently occupied” are, by and large, still under lease to undergraduate and other tenants. Violation of these leases by premature eviction for subletting without permission are against California housing laws. Other proposed spaces, such as the Escondido Highrise Apartments, remain under construction and are not equipped to house anyone, let alone those with pressing medical needs.
Petitions against non-pharmaceutical interventions may also fracture our community
Lastly, these demands are dangerous in their potential to ignite stigma, discrimination and xenophobia. The stigma associated with publicly or tacitly identifying and banishing individuals would discourage self-reporting of symptoms, and in turn, their tendency to willingly self-isolate. This would have enormous negative consequences for monitoring and maintaining control of the virus.
Moreover, to the extent the implicated individuals were a certain race, ethnicity, religion or otherwise — their unequal treatment is akin to any other form of discrimination. This is an especially tenuous issue given the President’s characterization of the virus as “Chinese” and “foreign.” And it produces the possibility that unequal treatment beginning bureaucratically (with housing, employment, or welfare for example) could rapidly deteriorate into racism, xenophobia and violence.
Indeed, these toxic tendencies have already occurred during the COVID-19 outbreak. Acts of hate have been committed across the globe against tourists, immigrants, refugees and asylum seekers — specifically of East Asian descent — amidst escalation of pandemic. As our own Phillip Zimbardo demonstrated on this campus not long ago, none of us are immune to the coercion of evil once it penetrates our environment. This would light aflame the same panic the authors claim to prevent.
Martin Niemoller’s Holocaust poem “First They Came” reads:
“First they came for [my neighbors]
And I did not speak out
Because I was not [one of them]
Then they came for me
And there was no one left
To speak out for me.”
Indeed, in pandemic situations — infectious, political or otherwise — it is natural for individuals fearing for their safety to distance themselves from the “ill.” However, it is not an accident that NPIs are also referred to as community interventions. Social distancing and other community interventions do not call for individualism so much as collective action, cooperation, and support in adhering to these extraordinary conditions during an unprecedented time.
When facing a shared enemy, unity is of the utmost importance. By acting together, we each can make a difference. Our community, as an exemplar to others across the country and the world, must (figuratively) lock arms in solidarity.
For the foreseeable future, in lieu of therapeutic options, it’s the best medicine we’ve got.
Eli M. Cahan
M.S. in Health Policy ’21 and Knight-Hennessy Scholar
A previous version of the article stated that the COVID-19 virus is unstable in aerosol form. In fact, though the virus is stable for a short period of time in aerosol form, it is not stable after that short time period. The Daily regrets this error.