By Lisa Gray, Staff writer
Dr. Gerald Parker is the director of biosecurity and pandemic policy at Texas A&M’s Bush School, and associate director of Global One Health. When we talked with him last month, he outlined what he believed will be the five stages of the COVID-19 pandemic.
Phase 1 was containment: The stage when known cases began to show up, but were not yet spreading in the U.S., Texas or Houston.
Phase 2, mitigation, began as the virus was known to be loose in those places, and extreme measures, such as Harris County’s stay-at-home order, were required to slow its spread, getting the Houston area past the peak of infections and hospitalizations and giving public-health authorities time to gear up for Phase 3: a new, more difficult phase of containment.
We’re entering that phase now. As of Friday, May 1, Gov. Greg Abbott is loosening restrictions all across Texas — for instance, by allowing the restaurants, movie theaters and malls to operate at 25 percent capacity.
On Wednesday, April 29, I talked with Parker about this new, second round of containment — the phase in which we try to restart our economy and learn to live with the virus.
There’s a lot of concern across Texas about lifting the shelter-in-place orders and entering what you’ve called Phase Three of the pandemic, the new round of containment. You’ve said that it’s harder to open back up than it was to shut down. Why is that?
For a number of reasons. There’s a lot of concern across the state and across the nation. On one hand, there’s fear. There’s worry about the seriousness of the SARS-COVID-2 virus, and people are not sure we’re ready yet.
But on the other hand, there are those that want to flip the switch and reopen our economy — our businesses and our industry — as though we’re returning to the normal that we knew before the COVID virus.
In reality, we are going to have to slowly converge into a new normal. We’re going to have to also assuage some of the fears and the concerns as we move forward. We’re going to have to mitigate risk as best we possibly can from the virus.
But we also have to recognize that continuing to shelter in place is not sustainable. The economic impacts of continuing to shelter in place are taking a toll on public health, mental health and other medical conditions.
So it’s not a question of either/or. We have to learn how to live with the virus. That’s why it is essential to begin to reopen our economy in a safe, measured way, phased in a responsible manner.
Is Texas at the point where it’s safe to reopen the economy?
I think we are at the precipice now of being able to safely reopen.
Some prerequisites have been stated in several of the roadmaps. They include that we are on a downward trend of disease severity. There are several measures of that downward trend. That could be anything from new cases on a daily basis, to decreased hospitalization, to decreased ICU admissions.
ON HOUSTONCHRONICLE.COM: Texas reports most deaths in a day just hours before stay-at-home lifted
In many communities in Texas, the data shows that we are on a downward trend of seeing a decrease in the number of new cases, or at least a decrease in the ratio of positive tests over total tests that are being run on a daily basis. That’s not for all communities; some communities are on an upward trend. But for the state as a whole, we are on the downward trend.
As for things that we have to have in place as we begin to move forward and reopen our economy, we have to have testing capacity. We have to have the ability to do contact tracing. We have to have protocols in place to isolate new cases, treat those new cases, and do the contact tracing they generate. Our healthcare systems have got to have the capacity to deal with new cases and treat effectively those who get severe disease.
All those prerequisites have to be in place. I think we’re making very good progress.
But we may not be ahead of the curve on all those things. In the last couple of weeks we have rapidly expanded testing. We have the capacity now to do 20,000 tests per day, and we continue to expand that capacity. And importantly,we are increasing our network to do that testing and provide results in a more timely manner. But we’re not where we need to be yet.
We are also planning to hire workforce needed to do contact tracing. The plan calls for rapidly bringing on board up to 4,000 people to support contact tracing, and that’s also going to be supported by people deployed by the CDC to help in training and guidance.
We’ve really been in good shape with our hospital capacity. We’ve been able to maintain our hospital operation, and we have plans in place in case we need to surge.
So we’re making good progress. I believe that we are on the precipice of, if not already meeting, those prerequisites across Texas.
Should we expect to see resurgence of the disease? to see the numbers climb again?
We must anticipate that we will see new cases. That’s only natural. As we begin to relax some of our shelter-in-place requirements, and as we have more human activity in our communities, we should expect to see an increase in cases.
We’re also going to see an increase in cases as we increase testing. So it’s going to be important to be able to differentiate, both at the community level and at the state level, the difference between a spike — a dangerous level of new cases — versus an increase due to increased testing.
Our job is to manage the curve now. We flattened it by staying home. Now we have to manage it — have to make sure that we can avoid a dangerous spike in new cases.
I hope we don’t see a dangerous new spike in new cases, but we should expect it. We should watch for it. We should be ready. It should not be a surprise.
If we see a spike, I assume that would trigger a new stay-home order or something similar. What sorts of triggers should we be watching for?
Each community is going to have to develop triggers independently of guidance that’s coming from the state — triggers appropriate for the level of risk in their community.
Some triggers are going to be straightforward, like the things I just spoke about — say, an increase in new cases. But even then we’re going to have to predetermine each community’s needs to say what would signify a spike in new cases — what the threshold is for a spike, and not just an expected increase because we’re testing more.
A better trigger as we move forward — particularly with enhanced testing — is going to be that ratio of positive tests over the total number of tests each day. Each community needs to establish a threshold that they’re comfortable with, calibrated with their hospitals and ICUs’ abilities to handle patients, and their ability to transfer patients to other communities.
Other triggers would include hospital admissions, and also fatalities, but we have to recognize that hospital admissions and fatalities are lagging indicators. After a person is infected, it may be seven to 10 days before they get sick enough and require hospitalization, and they might not die until three weeks to a month after an infection.
With lagging indicators, we may not know how we’re doing until we’re about a month into the reopening.
That means it’s important that we not wait for those lagging indicators. We need close monitoring by local public health. State public health is going to be essential.
We’ve talked about the public health army that Texas and the United States need. What sorts of people will we need to add, and how many, roughly? Do you have a sense of that?
The current plan is to try to ramp up, relatively quickly, to 4,000 people to do contact tracing in Texas. For the whole U.S., there are estimates that we’re talking about 100,000 people.
Qualifications to do contact tracing are going to include interview skills — to be able to interact with people well and also securely handle personal information. We’ll need to equip our contact tracers with technology so information can be acquired and handled in a very secure way and managed at the state level. And scientific writing will be an important skill set.
ON RENEWHOUSTON.COM: Coronavirus or not, these new doctors are matched and ready to work
We’re looking at harnessing the capacities of our health science centers at the universities across Texas — colleges of medicine, public health colleges, nursing schools. And there may be other disciplines with the right skill sets, like sociology, people who are adept at interviewing, at sitting down with people and talking about what’s happening in their life.
Could you walk me through what one of those contract-tracing interviews would look like? Would a contact tracer be working by phone? Would they call someone who has been diagnosed?
Ideally, it’s a face-to-face conversation, so you can get as much information as you can. When there’s a positive case, then we need to identify, with some degree of confidence and certainty, all the people they may have interacted with during the time period they could have been shedding virus.
That could be a lot of people. And sometimes it’s hard to remember who we came in contact with over the last 10 days.
And then it’s, where are those people now? And how are you going to locate them? And those contacts also had contacts with other people.
This will become a big data problem really quick. There may be too many people to interview in person, but it’s going to require that personal interaction.
Back in 2007, you were working in the Department of Health and Human Services during the George W. Bush administration. That was when the United States formulated its first pandemic plan. Was the kind of social distancing that we’re doing now in that plan? And what about reopening the economy?
I’m glad you asked that question. It was really the world’s first-ever pandemic strategy and implementation plan.
Under the George W. Bush administration, we did envision the need for invoking what’s called “non-pharmaceutical interventions.” When we have an infectious disease, everybody wants to jump right away to the technology solutions: We got to have a vaccine for it, we got to have a treatment for it, we have to have all these other kinds of high-tech solutions.
But in reality, with many infectious diseases, basic public health is critical to controlling disease spread. During that Bush era, we became students of the 1918 influenza pandemic. Philadelphia did not close schools and did not close businesses. St. Louis did. And there was a huge difference in the disease’s severity in those two communities. That shaped our thinking.
It’s interesting, in our community mitigation, strategy and guidance document, which was released in 2007, we did not envision wholesale closing of non-essential businesses. But as we’re moving now to reopening, we’re actually going to be applying many of the community mitigation (guidelines) that are in that document.
Social distancing is not going to go away. What we are doing is relaxing and relieving the most draconian other measures.
What explains the difference between New York’s rate of infection and Texas’? Why are we in such better shape?
Aggressive social distancing, implemented on a timely basis, can be important. For instance, in New York City, they implemented mandatory shelter in place on March 22, when they already had over 15,000 cases in the city. Today, they have almost 300,000 cases and 17,000 deaths in New York City.
Now compare that to Texas. We waited until April 2 before we implemented a mandatory shelter in place order. But the important data point is that we did so when the state had almost 4,800 cases — far fewer than New York City’s 15,000.
And that’d be an even bigger difference per capita?
Texas’ fatalities stands around 690 today, and our case count is over 26,000. So it’s a big difference.
Another thing I think played a part is that New York City has a higher population density. In Texas — even in denser places like Houston — we’re more spread out.
What else is on your mind these days?
I think that as we reopen Texas, we have to recognize that we all have responsibilities. It’s going to be absolutely essential that we continue to wash our hands and avoid touching our face. I think facial coverings are going to become more the norm for awhile, because we know now know that asymptomatic spread is a real phenomenon.
We’re going to have to build confidence as we move forward safely. So as we reopen our businesses, they’re going to have to be very careful to make sure that their safety measures are earning customers’ confidence.
I do believe the Texas plan is a measured and a responsible way to move forward. There’s no option: We have to learn how to live with the virus.
We also have to have a frank conversation about the risks. We don’t need happy talk. We need frank conversation about the risk.
Maybe we cannot eliminate the risk of SARS-COVID-2, but we can mitigate the risk and try to make it as safe as possible to move forward.
We all have a responsibility. Our business viability depends on that — and actually, our lives depend on it, too.
This interview has been edited for length and clarity.