As we hit a gruesome milestone — 100,000 reported deaths from the novel coronavirus in the United States — we must focus on the single most important part of the response: saving the most lives. As we confront the most devastating infectious disease threat the world has faced in a century, unless we are more careful, there will be many more avoidable deaths, not just from Covid-19 but also from the disruption it causes. If there’s one constant in the varying effectiveness of responses in different cities, states, and countries, it’s the tight correlation between how fully political leaders are guided by and support public health (for example, in Singapore, Germany, New Zealand, Seattle, and elsewhere) and how well they prevent their people from being killed by the virus. In lower-income countries where basic vital registration systems are often weak or lacking, this will require training, supporting, and paying community health workers and hospital registrars and also improving thecapacity to collect, analyze, and disseminate real-time data. At the height of the pandemic, a colleague in a New York City emergency department commented to me, “We’re seeing no angina.” It’s likely that patients with heartattacks avoided care for fear of contracting the coronavirus. In Africa, meanwhile, falling immunization and malaria treatment rates could cause millions of preventable deaths. If we fail to preserve the programs that address preventable killers, the number of people who die from the coronavirus directly might be a small fraction of those killed by other diseases because of the disruption the pandemic causes. The US Centers for Medicare and Medicaid Services (CMS) has made a good start requiring an end to nonessential visitors, but regulators, payors, and nursing home administrators will all need to keep the virus out with strict policies. Nursing homes need to find the virus fast with rapid andrepeated testing, and they need to stop outbreaks before they spread widely with rapid-response teams and test-based strategies. We need to identify and protect the highest-riskfacilities —not just nursing homes, but also prisons, homeless shelters, and factories, and the highest-risk individuals, including the elderly and those with underlying conditions. In a recent survey in Africa, half of respondents estimated they would run out of money and food in a week or less. Every country needs to find the balance, and this may mean allowing economically important activities to begin even before all of the ideal disease control systems are in place. In most places, most economic disruption from the pandemic isn’t fromlockdowns, but from fear — much of it rational — that everyday activities could kill us or our loved ones. We can save the most lives and protect our economy most effectively by urgently strengthening public health and emerging as soon and as safely as possible, focusing on the most important societal activities first. As future waves of the virus hit, we need to be ready to adapt rapidly to reduce spread, stop outbreaks, and protect the vulnerable.
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