Podcast: Shutdowns in COVID-19’s early days helped St. Louis area avoid thousands of deaths

Jim Dryden (host): Hello and welcome to “Show Me the Science,” conversations about science and health with the people of Washington University School of Medicine in St. Louis, Missouri, the Show-Me State. As we continue to detail Washington University’s response to the COVID-19 pandemic, in this episode we look back at some of the earliest days of the pandemic. A new study from Washington University researchers estimates that in the St. Louis area, the number of deaths could have increased by sevenfold had public health orders been delayed by as little as two weeks. The study was led by Dr. Elvin Geng, an infectious diseases specialist at the School of Medicine.

Elvin Geng, MD: It’s always tempting in public health to believe that if you avert a disaster, that there was no disaster to avert. It’s easy to think that you’ve jumped the gun when, in reality, you’ve really just dodged a bullet.

Dryden: Geng and his colleagues plugged data on COVID-19 infections, hospitalizations and deaths into a statistical model that tracks how the virus spread and they asked, “What if?” What if St. Louis-area public health officials had taken a wait-and-see approach rather than limiting large gatherings, closing bars and restaurants, ordering public schools to close, and issuing shelter-in-place orders? Geng says those actions in March of 2020 appear to have saved thousands of lives. Although not hit as hard as some parts of the country, by the middle of June of 2020 the St. Louis area experienced 482 deaths. Geng says a two-week delay in public health orders could have resulted in more than 3,000 deaths by mid-June. Part of the reason is that viruses tend to spread exponentially. Geng says the same sort of spread appears to be occurring now with the highly infectious delta variant. When Geng and I spoke about his research, just to be safe, we kept our masks on.

Geng: That’s actually a very hard thing for people to get their heads around because from the virus’s perspective, if you will, and this is sort of anthropomorphizing a little bit, but if you take the virus’s perspective, in some ways, going from one to two people is the same as going from two to four people, is the same as going from 20,000 to 40,000 people. But those things have vastly different public health implications. So when you go from one to two, it’s a very small problem. If you were to go from 2,000 to 4,000 to 8,000, that becomes a very big problem very, very quickly.

Dryden: And in this case, what you found was that when things closed down, when the stay-at-home orders went into effect, that may have prevented seven times as many cases as would have been there just a week or two later?

Geng: We tried to look at how much the virus was spreading here, using data from hospitalizations because those were the data that were most easily available. Asking ourselves, “What would have happened if the trends that were apparent at the beginning and the middle of March were to have continued after the social distancing policies for one, two or four weeks?” It’s important just to note that there are uncertainties around, sort of, the estimates themselves, but there are also uncertainties around the kinds of scenarios that we’re projecting forward, right? And so one important question about how credible these estimates are is what you think would have happened with the behavior of people in the environment had social distancing policies not gone into place, right? So you could say, “Well, maybe people would have just started to change their behavior anyway because they would have seen what was happening in New York or what was happening in Italy.” And so, even if no local policies were made, people would have changed their behavior anyway. I think that’s less likely for two reasons. One is that when you look at the data from cellphones in the area that tracked how people were moving in the St. Louis region before the social distancing policies, even while things were getting worse in other places and the NBA shut down in early March and stuff like that, people in this area, their movement didn’t really change hardly at all. But when those social distancing policies went into place, you could see that the median hours at home, the median distance traveled from home, and all those things changed very quickly. And so would some of that have happened without any sort of policies? I think it’s possible that some small amount of change would have happened, but a large amount of change would have been, I think, unlikely given what we had been seeing. In the paper, we do include some scenarios. Sort of, what happens if people were to change the amount of contact they had spontaneously by, say, 25%? The other characteristic of epidemics is that things really revolve around this fulcrum of a reproductive number of one. If it’s initially three or four — each person infects three or four other people — if there is some behavior change and it goes to two, it still doesn’t avert, sort of, severe epidemic scenarios because as long as that number’s greater than one, it’s greater than one on an exponential scale. It’s all about getting, sort of, that number at one or less.

Dryden: In those early days, we did not know exactly what was going on to spread the virus. I mean, I remember wiping down groceries at home and things like that that we aren’t doing anymore. We weren’t necessarily wearing masks early on yet. And in fact, a lot of the things that we know now that help slow the spread of the virus weren’t necessarily in place when these first orders went into place. Do those facts make those stay-at-home orders that much more important? Just the fact that you couldn’t find hand sanitizer on shelves, that sort of stuff.

Geng: Staying somewhat apart from each other physically is kind of like the oldest trick in the book when it comes to infections, right? And I was reminded the other day that the word quarantine comes from the plague in Europe, where ships docking in Italy, they would have to — the sailors would have to stay on for 40 days before they could get off the boat as a means of trying to make sure that they weren’t going to bring, sort of, an infection into the port city. I think at that particular time, number one, there were a few tools in the toolbox. We didn’t have a vaccine. Nobody knew which medications would work and which ones wouldn’t if you did get it, and there was just a number of tools in the toolkit. And it seemed using this one, which is a tried-and-true method, it was sort of a good thing to pull out of the toolbox early on. One of the things that I’ll say about this is that an epidemic has, sort of, I guess, a journey or a life cycle in a way, right? Because there’s a moment when the epidemic arrives and there’s a tremendous amount of uncertainty. But when the epidemic arrives, it is behaving somewhat differently than it does later when people have modified their behavior. You know, you could imagine sort of taking two perspectives on how to deal with it, right? One is like, “Let’s do something and then escalate when things get worse.” And then the other would be sort of like, “Let’s go all out and then back off when things kind of calm down.” Both are, in theory, reasonable ways to respond. I think in the long run, maybe the sort of escalate as you go could be a good approach. But at the very onset, the idea that we could sort of escalate as we go probably wouldn’t have been as effective as sort of going all out and then backing off. I mean, one of the metaphors that I haven’t thought about for a while, but at the beginning of the epidemic I felt like we were in a plane and we were flying a plane and no one knew exactly how to fly the plane. Right. And so there’s something coming in the distance and you want to avoid it. So do you turn hard or do you turn a little bit and see should we turn a little bit more? Given the fact that no one knew exactly how to fly the plane, I think the better part of valor probably was to do as many people did, as many municipalities and regions did, kind of, turn hard and then course correct if we’re turning too far away. It’s always tempting in public health to believe that if you avert a disaster, that there was no disaster to avert. It’s easy to think that you’ve jumped the gun when in reality, you’ve really just dodged a bullet.

Dryden: In the most recent paper and in another paper that came out not long ago, you did some public opinion surveying and found broad support for those policies. I wonder if that’s because in those days we didn’t know what was up. Because I wonder if you surveyed people now — completely anecdotal, just my observation — whether more people would object to the restrictions than did in those earliest days?

Geng: It’s hard to say. I think a couple of things. One is that I tend to believe that people’s views on the COVID response and on health, in general, is more moderate than what you get when you look at the media or Twitter or the comment section on a newspaper, right? Because the people that are the most vociferous are generally sucking up all the oxygen in the room and making the most noise. There are a lot of people who in general are sort of open to these ideas and are trying to weigh the best thing to do for themselves. It’s not that our sort of surveys couldn’t have been flawed as well, but we generally found there were a lot of people who were trying to deliberate between how to best navigate this epidemic in the context of their lives and their needs and their preferences, all of which are important and valid.

Dryden: What about you in those early days? Everybody else was ordered to stay at home. If you’re an infectious disease specialist at a medical center, you don’t stay home. Was that a nervous time for you? Not understanding exactly how this worked and having seen what happened in other places, wondering whether that might happen here, too?

Geng: I’m a practicing physician, but I do mostly research, and I think the real kudos go out to my colleagues, the doctors and the nurses who are, sort of, at the front lines of all this all along. And I think that they have been doing yeoman’s work for the entire sort of length of the epidemic, and that’s been, I think, a real challenge for many people. At the beginning of this in St. Louis, I think I definitely had moments where I felt like I was in an alien movie where the aliens were coming, but you couldn’t see exactly where they were and how bad it was. And we — many, sort of, epidemiologists and other people — were looking for clues. I was calling, texting with friends of mine from residency, who work at hospitals in New York City. And as the admissions in New York City were going through the roof, people sent a message like, “Our census just went from 50 to 350 in the last week.” And so there was a lot of, sort of, concern and fear about that. And I felt quite — I’m trying to remember how I felt about it personally. I definitely felt like there was an important set of decisions to be made. And I felt like I was glad to see that some public health officials were making those hard decisions in a timely way.

Dryden: What about now? We have a variant that seems perhaps more contagious than the previous one. Maybe it’s overblown in media, but we hear a lot about breakthrough infections, even among vaccinated people. And we’re not shutting things down. We’re going to ballgames, and restaurants are open and all that sort of stuff. And I wonder, assuming that lives were saved and cases were prevented by these orders all those months ago, whether we should be thinking about that now?

Geng: I mean, I think that with delta, there’s clearly a rise in cases probably over the last half of the summer, more than many people expected. But we’re nowhere near our peak in terms of deaths, right? And so that is some sort of solace that we’ve made progress in the public health response. Not to say that the amount of deaths that we have is acceptable; it’s not. And we need to make sure that we drive that to zero. But I think from an overall public health point of view, even though we do have a lot of cases, we are in a different place than we were. What is true is that the epidemic, I think, is increasingly heterogeneous. It’s going to be different in different places, depending on how much of the population has been vaccinated. So you have situations in pockets of the country where you actually have as many people who are severely ill in the hospital now as you did. That’s not true for most places, but there are select places in which that is the case. And so those are the areas that are of real concern. I think that in general, as a society, we could have done better in the journey that we came and we could do better now, sort of, going forward. I think a lot of that has to do with coming up with reasonable decisions in which we have collective buy-in, which is extremely elusive now, right? But I’ve always thought that, for example, in my opinion, from, sort of, a physical perspective, masks are relatively frictionless, right? You can do almost everything that you would normally want to do with a mask. You can go to a ballgame, you can go into a bookstore, you can do a lot of things. But there is a lot of social and psychological friction that has come with wearing a mask. Wearing a mask signifies certain things. I was out with my family, sort of, west of the city this weekend, and you could definitely see that it was an outdoor place, and probably like 60% of the people were not wearing masks and 40% of the people were. And there was definitely this group that was wearing the masks and the group that wasn’t. And so I think that it’s created — there’s a lot of sort of social friction around masking what does it mean to wear masks? And unfortunately, a lot of that has been manufactured, right? It’s come to symbolize something because we’ve wanted it to symbolize something. In reality, it’s just, in my view, anyway, a piece of cloth.

Dryden: Another thing that exists now that didn’t really exist in those days is better testing. It’s easier to get tested. You can do a rapid test at home if you want. Now, I’m not saying that people are testing themselves or using these things like they should, but that would seem to me another tool that we didn’t have that might make some of those draconian measures less necessary. Because if I feel bad, I can stick a thing in my nose and in 15 minutes have a pretty good idea of whether or not I should go outside.

Geng: What you’re pointing out is that there are a lot of things that we could be doing if that’s where our collective attention were, right? My gut feeling is that with delta, or even in the days before delta and before the vaccine, there were a lot of things that we could have done to mitigate the epidemic while allowing society to work as best as it can. You can imagine that maybe a lot of the public conversation would be around those things, or the technical things that people could do or making sure that everybody has access to testing, thinking about sending people tests in the mail. And that is one of the hidden costs of a public discourse that is all about, kind of like, looking for somebody to blame or something like that.

Dryden: Two groups, there’s the masked group and the unmasked group. I was out of town this last weekend on my way to a wedding, and at highway rest stops, for instance, I guess we had just a whole bunch of people who were vaccinated because there just weren’t any masks. And my reaction was kind of to be shocked by that. I wonder, am I overreacting? Is it as easy as if those people were wearing masks this thing would slow down?

Geng: It’s hard to know exactly what this would look like if everybody wore masks, but I think it’s probably fairly certain that all of it would look a lot better. I do think that if things were different and people were able to wear masks in those kinds of situations that you would see a reduction in the number of cases.

Dryden: Geng says that although the situation in 2021 is very different than it was in 2020, with many people vaccinated and much more understood about how to treat those who are infected, a lot of the behaviors that controlled the spread early on — like social distancing, avoiding crowds, and wearing masks — remain important to controlling the spread of the virus today. And he says that as kids return to school, concert tours resume, and theaters, churches, bars and restaurants slowly fill up again, it may take longer for viral spread to slow than it would if we had continued to use some of the public health practices that seem to have saved so many lives in the St. Louis region in the early weeks of the pandemic. “Show Me the Science” is a production of the Office of Medical Public Affairs at Washington University School of Medicine in St. Louis. The goal of this project is to keep you informed and maybe teach you some things that will give you hope. If you’ve enjoyed what you’ve heard, please remember to subscribe and tell your friends. Thank you for tuning in. I’m Jim Dryden. Stay safe.