As reopening begins, we worry about a second surge

AS THE COVID-19 pandemic begins to plateau, the population wants a reprieve from the continued stress, isolation and suffering. Massachusetts was particularly hard hit and our effective response required collaboration across all segments of our community, including government, businesses, health care and the public.

Optimistically, the Reopening Advisory Board just released new guidelines for phase 1 reductions of social distancing across the Commonwealth.

Despite the desire to get back to our usual work, we must acknowledge that only two of the proposed reopening indicators show a positive trend, and even those are far from where they need to be. We don’t want to be inundated in our clinics and hospitals again, but right now we are counting on it – if not this summer, certainly in early fall.

Critical to the state’s initial successes have been the health care workers – nurses, doctors, pharmacists, medical assistants, respiratory techs, and more – who have leaned into the fight. Public expressions of support for these frontline workers have erupted, in much the way soldiers and first responders have long – and deservedly – been thanked for their service. As family doctors, we and our co-workers are grateful for such widespread appreciation and public recognition. It is in this remarkable context that today, May 19, we observe World Family Doctor Day.

Family doctors quickly mobilized to the frontlines across all facets of the health system to fight COVID-19. At Boston Medical Center, one of the hospitals hit hardest, family doctors were indispensable as they were re-deployed from outpatient care into the hospital wards, ultimately treating about one-third of the hospital’s patients. Dozens worked on expanded COVID-19 inpatient wards, others helped to maintain essential hospital services such as obstetrical care, and as deaths began to mount, family doctors also stepped in to provide additional palliative care for patients and families.

In addition, these primary care doctors continue to care for patients using innovative methods to maintain essential services. Family doctors give children necessary vaccination, provide urgent care for patients who are not sick enough – or too afraid – to go to an emergency room, and conduct telemedicine visits to help patients manage chronic diseases and behavioral health needs, new and old. Most importantly, family doctors have often been the first providers to care for patients with symptoms of fever, cough, or shortness of breath seeking information on how to get tested, what to do for their symptoms, and if they must isolate or quarantine.

While health care workers are also eager to return to typical medical issues, COVID-19 continues to threaten more trauma. Many primary care doctors and their clinics are on the brink of bankruptcy, and the collateral damage due to the loss of access to routine health care is already leading to a number of excess deaths that may exceed those from COVID.

As the public appreciation and applause begins to subside, however, we must remember that we socially distanced to “flatten the curve” and protect our health workers from being overwhelmed on the battlefield. We know it’s still not a snow day, and that we need to remain cautious even as warm weather arrives. Kids still shouldn’t be playing in groups for now, schools remain closed, and we all must continue to distance until this threat is truly understood and under control.

This weekend, the Archdiocese of Boston will return to group gatherings for worship. Next week, barbershops and pet grooming salons will reopen and health centers may begin to see less urgent patients once more. In as little as three weeks, we could see retail stores and restaurants open again based on six designated public health indicators.

These measures include our testing capacity and the COVID-19 positive test rate. While the trend for these has been positive, 8,373 tests were reported on the day prior to the phase 1 re-opening with more than 1,000 positive cases, for a positive rate over 12 percent. This is far fewer than the minimum anticipated need of 70,000 daily tests proposed by Harvard, and the positive rate remains well above that of countries such as South Korea that have been successful in containing the virus.

One might be reassured by the declining number of daily deaths and COVID cases in hospitals, as well as the increasing unused capacity in ICUs. Tragically however, Massachusetts has lost nearly 6,000 lives to this virus – twice that of all the lives lost on 9/11 – and despite the slow decline we continue to lose nearly 100 people each day. Hospitals are still operating at expanded capacity, and there are precious few providers left to recruit to the fight should we see another surge of cases, potentially making the initial “flattening of the curve” for naught.

Most critically, more than 87,000 people have been infected in the Commonwealth, including the more than 1,000 testing positive the day prior to reopening. Despite the most aggressive tracking and tracing of any state, Massachusetts still remains below the estimated minimum need for contact tracing.

Certainly, there are restrictions that can be lifted that respond to the growing science, common sense, and people’s need to reduce isolation. For instance, outdoor activities with increased physical distancing, curbside retail sales, and an expansion of health services all may be relatively safe to expand with sufficient precautions.

In a setting where there is a combination of insufficient testing, tracking, and tracing however, even a minor increase in spread could quickly move beyond our ability to control the outbreak or manage the increased number of hospitalized cases. We are still learning about this virus – just recently, the WHO announced a dangerous post-COVID inflammatory syndrome in kids. The time it took for testing to register exponential growth from the initial spread of COVID was about three weeks. Just a few “super-spreaders” in churches or beauty salons could rapidly outpace our testing, tracing, and containment ability and overwhelm our hospitals and providers once again.

If we are to proceed on this proposed path for reopening, we must very quickly achieve the ability to test all who need it, including asymptomatic essential workers and all other high risk contacts at a pace much faster than the proposed target of July. Meticulous contact tracing must be implemented and continue indefinitely until a vaccine or cure, and ongoing monitoring and sufficient PPE must be ensured for all health facilities seeing patients of any type.

This World Family Doctor Day, let’s celebrate the family doctors who have played an essential role in fighting the pandemic. We can also support their practices reopening to maintain their viability and provide for your ongoing needs – but let’s also not lose the critical ground we’ve all gained in this fight. It’s hard, but we must continue to cover our faces, stay as distanced as we can, and avoid group meetings until these minimum measures are fully in place.

And sometime soon, call your family doctor. We look forward to seeing you again.

Jeff Markuns is physician at Boston Medical Center and executive director of the Global Health Collaborative in the Department of Family Medicine at Boston University School of Medicine. Suki Tepperberg is a family physician at the Codman Square Health Center in Dorchester and associate program director for family medicine at Boston University School of Medicine.