How Creating a “New Army of First Preventers” Could Help America Emerge From the Initial COVID-19 Wave

Dr. David Nash, founding dean emeritus of the Jefferson College of Public Health, discusses paths back from the age of social distancing.

The multitrillion-dollar question on everyone’s minds is an easy one to ask, but nearly impossible to answer: How, and when, will we return to whatever normalcy is after the COVID-19 pandemic?

Amid a lack of tangible answers—and the urgent need for mass testing amid fears that we could face a second coronavirus outbreak in the fall—we’re left to ponder “what ifs” instead of “these are the definitive next steps.”

Two scenarios have emerged as potential approaches:

  • After mass testing commences, quarantine those who need to be quarantined, which will limit the spread before we start on a path toward reopening society. Testing and quarantining continue until a vaccine is created.
  • Wait until we reach the other side of the curve before starting to reopen society, knowing that the emergence of hotspots would force us back into quarantine until there’s a vaccine.

Dr. David Nash—founding dean emeritus and the Dr. Raymond C. and Doris N. Grandon Professor of Health Policy at the Jefferson College of Population Health—has taken a broader view of the situation.

Dr. David Nash

“I don’t know if anybody has the right answers here,” Dr. Nash says. “Testing, more testing and even more testing. That is the key before anything can happen.”

Having sifting through reams of COVID-19 literature, Dr. Nash pointed to California Gov. Gavin Newsom’s six-point plan as “the most efficient description I’ve seen anywhere.”

Gov. Newsom outlined “six critical indicators” guiding when California would modify the stay-at-home order focused on the abilities:

  • To monitor and protect our communities through testing, contact tracing, isolating and supporting those who are positive or exposed;
  • To prevent infection in people who are at risk for more severe COVID-19;
  • Of the hospital and health systems to handle surges;
  • To develop therapeutics to meet the demand;
  • For businesses, schools and child care facilities to support physical distancing; and
  • To determine when to reinstitute certain measures, such as the stay-at-home orders, if necessary.

Dr. Nash, who also lauded New York Gov. Andrew Cuomo’s approach to “knowing what they’re doing and listening to the doctors,” localized those criteria to challenges we’re facing in Philadelphia and the surrounding region. There’s no catch-all approach to addressing the coronavirus outbreak.

Testing, more testing and even more testing. That is the key before anything can happen. —Dr. David Nash

“For Philadelphia, one of the challenges is that everybody must have an antibody test. We have to get that, and we hear everything from, ‘Yes, it’s coming,’  to ‘No, maybe it’s not.’ The answer is always changing, but this is crucial,” Dr. Nash says. “How else will we know who is really cleared to be part of the first wave to go back to work, to go back out in the communities? There is no clear path forward without testing, which is ironic because these are the things that people should have been working on two months ago.”

Even there, uncertainty exists, as details about immunity and antibody levels are not yet established, which is a crucial hurdle to surpass.

Beyond testing, Dr. Nash noted that a mechanism for tracking those infected must also be established so we can shift into a “test, track and quarantine as appropriate” mindset. Therein lies the nexus between the current situation and the one which Dr. Nash would like to see ensue in the future, based on lessons learned in other countries facing the pandemic.

In tracking those who test positive, those patients—and those they have come in close contact with—can be isolation, but “that’s going to take boots on the ground.”

“I think what it’s going to take is creating ‘an army of first preventers,’” explains Dr. Nash, noting that public health officials aren’t equipped with the resources or manpower to track wholly and effectively. “It’s dreadful to say, but I think all the problems of our crazy health systems are coming back to bite us.”

We have to be super careful here. I’d rather see them prolong the current situation than call for an early return. —Dr. David Nash

For Dr. Nash’s envisioned “army of first preventers” to become reality as “the gumshoes of fighting the virus”—akin to “contact tracers” in Massachusetts—it would take cooperation between the five academic medical centers in Philadelphia, along with public health officials.

They would have to create a curriculum and train first preventers in the nuances of the trade, essentially building the infrastructure for such an initiative to get started.

“Taiwan, Singapore, Hong Kong, Korea. Places that faced the SARS outbreak were ready to go because they had the infrastructure and respect for the public health apparatus,” Dr. Nash says. “Last year, of the total healthcare spending of $3 trillion in the United States, just 2.5 percent went to public health. That’s $275 per person annually.”

He drew a link between the idea with both the rising unemployment ranks and discussions which have started cropping up about reforming medical school curriculum in the post-COVID era.

The “army”—for which he drew an analogy to the “barefoot doctors” who took health care into China’s rural areas in the 1960s—could include those who lost jobs in the wake of the economic impact of the shutdown orders, along with the incoming medical school classes later this year, he suggests.

Jefferson nurse standing at mobile testing site at TJUH

“These community health workers would be our version of that, talking with people in barbershops, talking about food insecurity at local churches, communicating with people we rarely communicate with,” he says.

“Let’s pivot that to be the trackers and educators because it is disproportionate in those communities,” Dr. Nash continues. “Nobody pays attention to the Department of Public Health unless there is a salmonella outbreak or they release a list of what restaurants people shouldn’t go to because of health-code violations.”

His pressing fear is that the social-distancing restrictions would be lifted too early, thus bringing about another situation where stay-at-home orders would need to be reinstituted in a second effort to flatten the curve.

“We have to be super careful here. I’d rather see them prolong the current situation than call for an early return,” he says. “I certainly understand the economic hardships being created, but the only reason we’re not in a worse jam right now is because of what we did. There is no question that it’s worked. We can’t risk that. Once the horse is out of the barn, it’s hard to put it back in.”

Ensuring that adequate testing and tracking are in place could help avert such a situation, and Dr. Nash advocated for Jefferson being a major part of helping to “organize, deploy and educate” the trackers.

“It’s like Dr. Stephen Klasko said in the Philadelphia Business Journal recently: This is a great opportunity for the five academic medical centers in the city to work together. What a great springboard for collaboration this could be, a collective effort,” Dr. Nash says. “We could really do some great things working together.”

Concludes Dr. Nash, “We need to make sure the region is covered in a way where you’re not getting electricity from five different utility companies. Just as the greatest generation built the arsenal of democracy, we need to build the arsenal for population health and we need a new army too. In addition to first responders, we need a new army of first preventers!”

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