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Dr. Jan Carney says the evidence is clear that social distancing measures will slow the spread of the coronavirus. But what happens after the growth of new cases peaks?
“Once we start to see a small decline, everyone wants to go outside,” said Carney, the associate dean for public health at UVM’s Larner College of Medicine. The right thing to do? “Just pause for a minute.”
Carney, who also served as Vermont’s health commissioner from 1989 to 2003, said dealing with a novel virus means evidence is hard to come by: Decisions about when to lift certain restrictions will largely be based on the experience of other countries that are just weeks ahead of the U.S. in their responses to the outbreak.
Social distancing measures should stay in effect “for as long as practically possible,” Carney said. “Because if we open up everything we did too quickly, is there a worry that we could see some more disease coming back? I think we have to wait and see.”
In an interview this week, Carney discussed how she’s tracking the spread of the virus, why she believes the science behind social distancing is sound, and why it’s too soon to tell when Vermont will be out of the woods. This conversation has been edited for length and clarity.
I feel like most members of the public probably, in their daily lives, don’t think about epidemiology. Now, it seems like epidemiologists are kind of the only people we can trust. How does it feel to be in such high demand all of a sudden?
This is a public health practice. And we’re hearing those two words — “public health” — almost every day now.
The language of public health is really epidemiology. But the work of epidemiologists day to day, in every community in America and across the globe, is something that remains often invisible until something happens. Then you sort of see a little bit more behind the scenes about what they’re doing and how they’re doing it and why they’re doing it. That’s very much in the forefront today.
Is there an aspect of this field that you feel like people don’t understand — that if they understood better how you did your jobs, that they might look at this current crisis differently?
I think that again, the work of knowing, and now even more formal training of public health, is coming to the forefront. I think that the public understands very well what doctors and nurses do. You know, you go in and you get health care. But there’s this whole system — across the country, many states have these county and local health departments. Every state has a state health department.
Within that, there’s all kinds of things going on to both protect and improve the health of the public. And they have a complementary role to that of health care. They deal with populations, and they deal with prevention. And some of the things that are being tracked in the state of America on a national level — and have been for many, many years — are diseases that are contagious and of concern to the public.
They also track and depend on very close relationships with laboratories and health professionals all over about new and emerging infections, new syndromes, things that don’t seem quite right. When you start to pick up on those, it might be that there’s something very different or unusual going on. And that’s what’s been happening here.
When you look at the numbers of where we are now in the state of Vermont — what statistics exactly are you looking at, and how do you go about reading them?
Certainly you can look at the World Health Organization — they’re doing these case counts, and you can look at those on a global scale. Looking at the CDC, Centers for Disease Control and Prevention, and all of their daily statistics.
But you’re also looking at the trends over time. You look at what’s happening, how many people, and then what is that place? And then, what do we know about those people, and particularly the severity of the disease in those people? And then, what’s happening over time?
In terms of where we are right now — when you look at those trends, what are you seeing?
I see here in the state of Vermont, across our entire country, growing numbers. And they’re growing at different rates. For example, the situation in New York, right next to us, is extraordinarily serious. We’re also seeing high rates in Washington, and we’ve been hearing about that. And California and also the South. You look at the trend and the trend is up, right? And likewise, the state of Vermont.
So what do we know? What do we do? Who do we work with? And what can individuals do?
One of the things I’ve been talking about on a daily basis has been the science behind these social distancing recommendations. You know, do they really work? And is that our best protection? I think the science of social distancing is really compelling. And I can tell you a little bit about why I think that works.
Some of the lessons are from a different infection — one that we have a lot of evidence about what happened, which was the pandemic flu of 1918 and 1919. There’s a couple of studies that I talk about. One was, they did a study of that pandemic, and they looked at different mortality rates in United States cities. They looked at more than 20% of U.S. cities. And they found that there were differences in those actions that were taken.
The ones that did what we call social distancing — they closed the schools, they stopped public events, they isolated people who were ill from other people — it really separated people from each other. The ones that did the school closures, the isolation, and that also did that stopping of public events, had a reduction in deaths and serious outcomes from that pandemic that was different from the ones that didn’t. I think that’s a lesson that lasts over 100 years.
Wow. So you’re saying what we’re doing right now is directly related to evidence based on what happened back in 1918?
Yeah. And there’s more evidence from this current COVID-19 pandemic we know from over 100 years ago — that those strategies were very effective in reducing the most serious outcomes, deaths, from that pandemic.
Now, everything’s relative. So I’m not saying that the time and place from 100 years ago are 100% directly relevant right now. But the principle, I think, is the same. They were able to do that social distancing over a period of — in that study, it was about 10 weeks. And that showed a dramatic difference.
So what does that mean right now? Some of the recent papers that are coming out, and also the modeling that’s coming out, is from the countries who have already experienced it or passed the peak of this. As an example, there was an article from the CDC that looked at Singapore and showed the impact of their disease surveillance. They did more testing, and that enabled them to quickly isolate people who are sick. And they also did those same kinds of social distancing things that were done in 1918 here in the United States, and those were effective.
And it’s not just the government, what the government is saying. It’s what individuals do. To me, it’s kind of common sense, right? If you are staying apart from other people, and you might be coming down with a viral illness, well, you’re not going to spread it to somebody else. Or if you’re already sick, and you’re here apart from other people, that reduces the number of people you spread that infection to. So these kind of social distancing principles that we’re doing, like right now here in Vermont, they protect ourselves, protect our families. They protect our friends, they protect the people we work with, and they have a huge impact on disease rates in the community.
I’m curious, how do you know when to put these social distancing restrictions in place? How do you know when on that curve is kind of the sweet spot for when you can really make the most impact?
My short answer to that is, the sooner the better, and keep them in place as long as practically possible. No one knows exactly how long that is.
The value of doing it early is that you’re in a position where you know that things are getting far worse in other areas — to stop that from happening. So it gives you the potential for prevention.
As an example, what we did here in the state of Vermont, I thought was really, really good. It was strong, it was expansive, it was across the board. It was those exact same kind of social distancing strategies that we know work, all the way from that 1918 pandemic. And we continue to repeat them. People seem to be listening. If you go out, many places are far less crowded, and we’re telling people to do their best to stay at home.
You’ve talked a lot about what it’s like to look at this data and look at the trends. Are there things that the data doesn’t show?
Let me talk about that in a general way. Sometimes when this happens, it happens really, really fast. For example, they had to first sequence the genome of the virus, then they develop the test. You’re just going really, really fast while you’re trying to understand who’s getting sick, how to prevent that, do the public messaging, trace who exposed whom, and try to isolate them and just use the basic strategies.
I think in this case, we don’t necessarily have the luxury of having widespread data about: what is this infection rate truly across the board in the community? First, tests had to roll out. Then, the kinds of studies that can be done — in terms of really looking at the specifics of household spread and community spread — it was just moving too quickly. And you have to spend your time trying to prevent it any way you can and take care of people who are sick.
I think that moving forward, some of these studies that are going on now will help elucidate that in hindsight, but there’s never a perfect world in the time of a pandemic.
In terms of where we are right now, it does feel like we’ve entered a new phase of this crisis, where the restrictions have been put in place, everyone has at least started to adjust to them. We’ve gotten used to social distancing — it’s kind of entered everyone’s vocabulary at this point. What is the next shift on the horizon? What is the next phase of what this crisis looks like here in Vermont and in the U.S.?
I think it’s really hard on a personal, individual, family, community level to see what’s happening across the country, and things getting worse, and to remain confident and rest assured that what they’re doing, they need to keep doing that. Staying the course — you know, everybody all in on this — and reassuring each other and supporting each other, to staying physically apart from other people for a little longer than we might have thought we were going to have to do it when we started.
Some of the public message is to say: keep staying distant, keep staying apart from other people. But keep connecting with people. Make sure you remember the rest of your health. You can still go outside when the weather gets nice — that’s something that’s a real positive. We’re finding ways to connect with people, keeping up with school, depending on your age. Those kinds of things. I think staying the course, and being comfortable with it, and sort of knowing deep inside that this is absolutely going to help us.
But you’re saying we might not see some kind of major turning point in the way that this is developing for quite a while.
I can’t predict that. I don’t think anybody can predict that. I think we’ve seen the trends, and nobody knows when that’s going to be. I think what we can be confident in — if everyone in their respective roles is part of being physically apart, but socially connected to people — if we’re able to maintain that for the long term, we will watch, and there will be serious outcomes, but we’ll have spared thousands and thousands of people from those.
When do you start to get signals that this might be coming to an end? What kind of things do you look for?
I’m looking at the major sources of literature. We’re looking at the World Health Organization, the Centers for Disease Control and Prevention, and the Department of Health of course, as the major sources. The New England Journal of Medicine puts out regular articles that are publishing results of what’s happening in other countries who have already gone past the peak.
I think everyone’s looking at those and their experience. How fast is that happening? What did they do? And is there anything we can learn from them? And I think you watch that for certain countries in Europe as an example, that are doing more poorly than others, and everybody is following that sequence here in our country. You know, when something peaks, what are people doing? How are they doing it? What can we learn so that we can end it right here in our own state, our own community?
It sounds like you’re saying it’s a little bit too early to even know what those signals are going to be.
We can look at the data from the CDC website and look at their maps. And I have great confidence in how they do their jobs. And we can look at similar findings here in the Department of Health. When we start to see there’s a peak, and now the serious outcomes or the people testing positive are starting to go down. That’s what people are looking for.
The other thing is that even when we watch this curve, and we might see them start to come down and we relax a little bit, we still may need to maintain the social distancing for a while longer. Some of the newer data that’s coming out is saying, we’re going to have to be really careful to make sure things are really at a low level.
Once we start to see a small decline, everyone wants to go outside. But just pause for a minute and wait for those recommendations. Because if we open up everything we did too quickly, is there a worry that we could see some more disease coming back? I think we have to wait and see.
We’ll have plenty of information from the CDC and our own health department. We’re learning more and more every day about experiences from other countries and what people are doing in our state. I think you do have to be patient and wait to see.
