Resetting Public Health Strategy on COVID-19

Thursday, November 19, 2020
Daniel Acker/REUTERS

Senior Fellow for Global Health, Council on Foreign Relations


Vice President for National Program and Outreach, Council on Foreign Relations

Jennifer Nuzzo, epidemiologist and senior fellow for global health at the Council on Foreign Relations, provides an update on the recent increase in coronavirus infections across the ​United States and the world and discusses best practices for developing public health ​strategies at the state, local​, and federal level​s. 

FASKIANOS: Good afternoon and welcome to the Council on Foreign Relations State and Local Officials Webinar. I'm Irina Faskianos, vice president for the National Program and Outreach at CFR. We're delighted to have participants from fifty-two U.S. states and territories with us today. Thank you for taking the time out of your busy schedules to join us for this discussion, which is on the record. As you know, CFR is an independent and nonpartisan membership organization, think tank, and publisher focusing on U.S. foreign policy. Through our State and Local Officials Initiative, we serve as a resource on international issues affecting the priorities and agendas of state and local governments by providing analysis on a wide range of policy topics. CFR is also the publisher of Foreign Affairs magazine. We're pleased to have with us today Dr. Jennifer Nuzzo. We shared her extensive bio with you so I'll just give you a few highlights. Dr. Nuzzo is a senior fellow for global health at CFR. She is also a senior scholar at the Johns Hopkins Center for Health Security, and an associate professor at the Johns Hopkins Bloomberg School of Public Health. Her work focuses on global health security, including pandemic preparedness, outbreak detection, health systems and infectious disease diagnostics. Additionally, she directs the outbreak observatory at Johns Hopkins, which conducts research to improve outbreak preparedness and response in partnership with frontline practitioners. So Jennifer thanks very much for being with us today. We are just a week out from Thanksgiving; we have seen an incredible increase in the Coronavirus, virus infections as well as deaths. So can you give us an overview of what needs to be done, public health strategies for addressing this increase right now at the state, local and federal levels?

NUZZO: Sure, and thank you so much Irina for the introduction and for inviting me to participate in this. I consider it a real privilege. I started my career in local government, and so I've seen firsthand how much change actually happens at the local level. And I think when it comes to this topic, given what we're potentially looking at in the weeks to come, making change at the state local level is going to be absolutely critical. So very much appreciate the opportunity. So just maybe, I mean, we all know how bad the situation is right now. But just to put it into perspective of where we are now versus where we have been, basically what we are now seeing our historic highs in terms of the number of new cases of COVID-19 being reported in the US each day. Since the beginning of November, we have routinely seen more than 150,000 new cases each day, which is completely historic, in terms of where we've ever been, even, you know, pre shutdown levels in the spring, we were never even remotely close to that. And this situation is you know, I'm sure everybody on the line here is well aware, this is really a fifty-state problem right now, with nearly all states seeing rising case numbers. And even more worrisome, we're seeing historic highs in terms of hospitalizations. And that's particularly troubling because over the summer, we at least had the observation that the percentage of cases that were resulting in hospitalizations and deaths had been declining. But those gains that were made over the summer in terms of possibly improved outcomes from COVID infection are in part contingent on there being adequate capacity in the health system to be able to respond to those cases. And so you know, as we're hearing stories of hospitals being overwhelmed the doctors and nurses being overwhelmed the tricks that they've learned how to manage their patients, it's going to be very difficult for them to apply under circumstances where they're they just are seeing so many patients. So we're in a very worrisome situation. And looking ahead, you know, with the prospect of the holidays coming and people potentially hosting indoor gatherings, seeing people that they haven't seen in a while, traveling potentially, I heard the CDC today just recommended that people do not travel for Thanksgiving. But, you know, we'll see what people choose to do. But the prospect that they could obviously worries us quite a bit in terms of the potential for our epidemic to accelerate even further. We're also entering the winter months and so the likelihood that people can kind of have safer activities outside is decreasing. They're probably going to increasingly take it indoors, which increases the risk of transmission of this virus. And then also everybody is sort of worried about what it could mean with the start of flu season and how much harder things could be. So looking ahead, there is a lot of need to act and to act quickly. I see what we need to do sort of in three areas; the first one is taking immediate action to try to reduce the spread of this virus. The second one is to protect. Continue to protect, but in some cases enhance our protection of vulnerable populations. And the third one is looking at sort of the economic issues. And I'm going to spend some time talking about that, because sometimes it's portrayed as sort of being you either care about the virus or you care about the economy. I argue you have to care about both at the same time if we want to get out of this situation that we're in.

So in terms of reducing spread, we know what we need to do. I will tell you, as an epidemiologist, I am personally much more interested in having the capacity to implement targeted interventions. These are the things you've heard about testing, contact tracing, isolation, and quarantine, those measures that go after individual infections, we know that those work quite well. Other countries have used those almost entirely in order to keep their epidemics from accelerating, and they have avoided shutdowns. However, as much as I greatly prefer those measures, because they are, like I said, targeted to what we are trying to achieve, and they carry fewer harms than broader population based measures like shutdowns, it is incredibly difficult to do those in the face of the case numbers that we are now seeing. And so I think, unfortunately, in a lot of places, we have probably likely exceeded our capacity to rely solely on those measures. And in places like that, we are probably on a path to further shutdowns. Now, my hope is that if there are shutdowns, they can be, we could try more targeted approaches, not you know, an entire statewide lockdown, but hopefully, more targeted closures that are aimed at those venues where we think the virus is likely spreading. You've probably heard a lot in the news about family gatherings as being important for transmitting this infection. And it absolutely stands to reason that if I were infected and didn't know it and showed up at a family gathering, there's a good likelihood I would infect, a number of people at that gathering. But if we only talk about family gatherings, which are incredibly hard to stop, we may not get where we need to be. And so what I think we need to do is figure out in the scenario I just gave you, where did I get infected in the first place? And if we can figure out those places, those places in the community that are starting these clusters of cases, in family gatherings, I think we'll have a better shot of getting ahead of this virus. Now, we don't have great data on that. But chances are it's the places that we have worried about in the past, which is indoor dining, places like gyms where the transmission risk is quite high, those indoor environments where it's hard to wear a mask, it’s hard to maintain the ventilation that you need, and it's hard to keep the physical distance between people. Arizona, I don't know if anybody's online from Arizona, there's sort of an inspiring story in terms of what happened over the summer, in the first two weeks of June, they saw 150% increase in their cases, and through a statewide mask mandate and targeting some restaurants and gyms and other things, they brought their cases down quite considerably. And so I think that at least raises the prospect that if states do have to implement new restrictions, that they don't have to do everything like we did back in the spring, at least, that's my hope. So first priority is doing what we need to do right now to get our case numbers back under control and that hopefully we can then start again, using those targeted interventions going forward. I personally think it's incredibly important that we prioritize schools. And, you know, as a mom of two kids, when I see many places in the community open, and yet my kids are able to go to school, I question those priorities, because our children are really suffering under that.


The next area is on protecting the vulnerable populations. And you know, in the spring, we saw really deadly outbreaks associated with long-term care facilities. And I am still worried about these places going into the fall, in part because though we've gotten better at protecting them, when the rates of infection in the surrounding community increase, there is the great likelihood that the virus will find its way into these facilities and again cause deadly outbreaks. In the spring, about half of the US deaths were attributed to these facilities. And so it's really critical that we make sure we do everything possible to protect them so that we don't have surging death numbers yet again. The federal government has provided some tools in terms of testing supplies, but I worry about the ultimate availability of these going into the fall. We could once again see testing shortages and also shortages of personal protective equipment. And it will be really critical that these facilities have priority access to those supplies if they become in short. If there are shortages again.

We also know that not everybody has the same has been if not all parts of our community have been affected equally by this virus. And so we know that African American and Latino populations are disproportionately represented among our COVID case numbers, our hospitalizations, and our deaths. And so when we think about protecting vulnerable communities, I think we have to prioritize those communities that have been hit hardest and figure out whether they have enough access to the resources that are important for protecting themselves. One thing that I personally have been digging into is testing access. And there is some evidence to suggest that testing isn't as well distributed in the U.S. as it needs to be. And in particular, if we're relying on sort of, you know, chain stores, pharmacies and things to provide a lot of our testing, we just know that they don't typically exist in underserved populations. And so we need to kind of make sure that the resources that are being offered are meeting the needs of the communities that most need them. So that's on the protecting the vulnerable.

And then the third one is on the economic side. And I will tell you, I think we have absolutely fought for a false battle between economy and public health. They're deeply -- they're both dependent on each other. And one of the ways I think our public health response has been hobbled is because we have failed to address the economic disincentives to comply with public health orders. And in particular, there have been some reports of decreasing use of tests. And, you know, just kind of put yourself in this scenario, if you are someone who feels fine, but may have been exposed to COVID, or hearing about the importance of being tested. You feel fine, but know that if you do test positive, you may be not able to report to work for close to two weeks. That's a potentially enormous disincentive. Similarly, if you test positive, you might have to, you know, be out and lose your income or tell about the people that you've come in contact with during that time, who then may also have to stay home under quarantine. And so there is enormous disincentives, which, in the field of global health, we have already learned that it's important to remove disincentives and to, you know, to address disincentives to remove barriers, to get people to comply with public health interventions. And we, for some reason, have absolutely failed to do that in this country. Other countries haven't other countries pay people to stay home, if they test positive. They shouldn't have to choose between, you know, earning an income and  not spreading the virus. And so that's an area where I think we need a lot more attention. And it's not just, you know, paycheck, it's also other support, something in public health are called wraparound services, some people need help to stay home. They may have family responsibilities, they may not have a safe place to actually stay home without infecting others, or they may need you know, meal help or things like that, that require additional social services. Those wraparound services are also I think a missing piece of our response. And if we don't remove the barriers, it's going to be very hard to make sure that everyone is able to comply.


One other aspect of the kind of economic situation that I want to address is just looking forward. And maybe we could barely kind of see this through the fog of the war that we're in right now. But I am deeply worried about the economic harms of the virus and our response to it and what it's going to mean for state and local budgets in the future. And in particular, I'm worried about this because of what happened in 2008. And the global recession that we saw, you know, everybody had to kind of tighten their belts, and there was cuts in federal funds for certain programs. And, you know, this had enormous consequences for public health programs. And in my view was possibly one of the single most damaging event in terms of our overall preparedness for events like COVID-19, there was a study that said that the job losses that followed the public health job losses that followed 2008, possibly eroded about a fifth of the public health workforce. And the truth is a number of the things that we're struggling to do right now, like contact tracing, in part, the reason why we're struggling to do it is because we haven't been doing it in recent years, because we haven't had enough people working in health departments to do it. So as we start to come out of this, and at least going forward, this is not the place to cut. One, because this unfortunately is not going to be the last or possibly the worst event like this that the country will face. And so I want to kind of put in that early plug to say, you know, we can't get again entering a phase of neglect. We will really suffer for it if we don't. And then the last thing I'll just say is there's been some good news as of late with respect to the vaccines being developed. And I think we all deserve some reason to feel optimistic. And I think the scientific results regarding the vaccines are certainly reasons to feel optimistic. So that is good news. But it's not as you probably all are aware, a vaccine that saves lives, it's a vaccination and making sure we can link, what are probably initially going to be very limited supplies of vaccines to the people to whom they are supposed to go, is going to be the work of state and state and local governments. And in my view, they have not, you have not gotten enough support. In order to do that. There have been some estimates of you know, the resource requirements or, you know, possibly up to, you know, $8 billion, there have been requests to the stimulus for this money, but my understanding is to date, I think state, local governments have only gotten about 200 million. And so this is an important piece of advocacy, because if we want to make best use of these vaccines, we need to make sure that we can get them to the people who need them as quickly as possible. And that is a whole level of difficulty and logistics that requires planning and requires planning now, and unfortunately, will require resources, including for the fact that one of these vaccines needs specialized freezers that, you know, don't routinely exist in the usual healthcare infrastructure. So anyway, I think there is reason to be hopeful for the future. And I think that the task ahead is absolutely one that we can meet. But it's going to require a lot of work. And I'm very grateful to all of the work that state and local governments have done I mean, really, in the what was basically been a leadership vacuum, you know, we have seen states really rise to the occasion in order to protect their constituents. And that has been very inspiring to me. And I just, I'm really so grateful for all of your effort to save lives, and to help try to lead the country out of this. So thank you so much.

FASKIANOS: Thank you very much. That was terrific. Let's go now to all of you for your questions. And, you know, we also ask -- want you to share best practices use this form to share best practices, so that you're supporting each other. So if you want to click on the Participants icon in the bottom of your screen and raise your hand there, or if you're on an e-tablet, you can click on the More button on the upper right hand corner and raise your hand there. And please say who you are, and what state you are from. That gives us context and helps Dr. Nuzzo answer your question. Okay, so the first question goes to Janice Wiener. And, yes, you unmuted yourself. Fantastic, we can hear you.

Q: My name is Janice Weiner, and I'm on the city council in Iowa City, Iowa. We have enormous challenges here in Iowa. Our governor has finally put in place a partial mask mandate that's more confusing than anything else. One of the biggest challenges we face since the beginning is figuring out how to do anything locally, because the governor has an emergency proclamation in place. Sorry, my granddaughter's in the background, has an emergency proclamation in place, which occupies the legal field and limits our ability to put local measures in place. We have put in both that as a city and as our county face covering mandates. But that is about all that we can legally do. So do you have any suggestions on, first of all, how to get beyond the political polarization of this, because this is a blue area in a very red and what's really a very red state now. And secondly, how we at the local area in the local area can put in place something in addition to what we've already done in the public messaging we're doing to try and get this message across. Because as you may have also seen on the news, our health care facilities, including the biggest in the state, here, University of Iowa clinics, are really getting close to being overrun. Thank you very much.

NUZZO: Gosh, this is you're not the only locality that has been in a situation where your hands are a little bit tied. I don't know, obviously, what the legal options are. I will just say it's incredibly difficult situation to be in and I guess masks are just one piece of it. I think it's a very important piece of it. But we also have to just look at the other gatherings that are happening. And you know, sometimes it could be less about restrictions and more about offering alternatives to allow people to do things in a safer way. I know that's incredibly difficult. And it's also resource intensive. I will say I think on the communications challenge, particularly given how politicized something as simple as masks has become diversifying the spokespeople might, I'm sure you're probably already doing this, but working with trusted local leaders to take the message forward. Perhaps that will land better than having it seem as a as a government initiative. I have been quite impressed by the leadership of businesses in order to kind of enforce requirements where government has failed. And that's possibly another option. I mean, this is really in their economic best interest. This is one of our, I mean, this isn't this isn't hurting our, the measures that we're taking to make ourselves safer isn't what's hurting our economy, it's trying to get ourselves as we get this virus contained as quickly as possible so that we can go back to some level of, economic, you know, growth and recovery. And so I don't I unfortunately don't have great solutions for you, other than trying to enlist local leaders. And you know, I think this is also a time when data and facts are called into question. The counter is not more data and more facts, but more stories from people who have gone through these experiences themselves and letting the stories lead and kind of appeal to people's kind of sense of, you know, humanity versus statistics.

FASKIANOS: Thank you. Let's go to Gary Scarpello.

Q: Gary Scarpello, Commissioner in Upper Dublin Township. You know, a lot of what we try to do, of course, we're hamstrung by both federal level and state level politics, both in the distribution of the Corps’ aid and all of that, and what may or may not happen down the road. But really, you know, you make a lot of sense. We've all been saying that too here locally, that we have to keep the economy going. But we have to do it safely. In order to do that, we need to tackle the virus. And we do have to do it all together can't be one at the expense of the other, it needs to be holistic. But really, the bottom line problem has and continues to be the right wing talking points that are just permeating society from every which way. From social media to regular media to locally here when you know, you try to talk to local people in our community and, and they're up in arms, and they're ready with their pitchforks to, to go after anybody that talks about any of the things that actually do work in controlling the pandemic. So if we're going to really make a difference, we need adults in the room, the Republican Party needs to stand up, and the dialogue nationally needs to change. How can we get this done? What can you do on your level? What can we do on our level? It's got to change.

NUZZO: I agree and I don't have a solution. I will just say I think one is where the public health messaging has failed to date has just to take an empathetic approach. To recognize that people are so I mean, people are suffering and to acknowledge that the economic suffering. I mean, I think sometimes in a public health messaging world, there's a worry that if you sort of acknowledge that it might not be fun to wear a mask, and people don't like a mask, that that it will give credence to people who don't want to wear one. But I don't think not acknowledging people's feelings about the sacrifices we are all making right now is helping us. We obviously again, this goes back to when people are have their own facts, it's hard to combat that. But I do think that reaching out to people like as connecting to them as humans, and trying the best to say, “Listen, I know I hate wearing a mask, too. It's terrible. But I like less having to stay inside my house. And I like less the fact that my local coffee shop has to close.” So I don't know, I'm sorry, I don't have I don't have great solutions to the state of political affairs that we're in. But I do think that we need to start by acknowledging all of the sacrifices that people are making in this situation.

FASKIANOS: Charles Isenhart, wrote, he's a state representative in Iowa, do you worry that we're obviously seeing public health institutions and personnel being ignored discounting, sometimes even attack for intervention efforts, even by elected officials on whom the system relies? How will this all weekend the public health system going forward?

NUZZO: I deeply worry about it. I think this the state of our politics right now is completely unnerving and troubling. And it's not just public health, but public health is sort of the latest casualty. I mean, I really think part of the problem is that we all seem to be operating off of our own set of facts. So I do worry about it. The only thing that makes me a bit hopeful is that if even if you don't care about public health or you think it's you know, you're frustrated with the situation that we're in, is that there are reason why these agencies were stood up and created, and that need will not go away. I mean, you know, nobody wants, you know, the harms that are going to come. And so I do think, you know, it'll take time to build back trust. And this is why I think having partnerships with local leaders and just you know, prioritizing those communications and those regular communications, going forward is going to be absolutely essential. And, you know, doing more deliberative approaches, talking to communities about the planned interventions and trying to find out if that works for them, and if not, why, and trying to come up with solutions. I mean, I think part of the problem has been that in the face of this, this emergency, absolute emergency and the urgency of the emergency, we have sometimes taken the expedient route, for the purposes of saving lives. But there are some things that are lost in that. And so if our, if it's easier to say, no, we're going to restrict all of these things, as opposed to say, okay, let's help the community find safe alternatives, so that they continue so that they can continue to do the things that are really important to them. To continue to have worship services during one of the hardest years of probably our recent times. Can we find a way to do that more safely, just so that people don't feel like this whole thing is happening to them, and that they have no input to it?  I really think trying to find ways to have to provide local input to some of the decisions, recognizing that obviously, you know, there still is a need to protect lives and to act expediently. But if we can try to do more of that in the future, I think it'll be helpful.

FASKIANOS: Thank you. Let's go to Sheila Vaughn.

Q: Oh, thank you so much. I'm Sheila Vaughn; I am a selectman in Kingston, Massachusetts. And I am also on the school committee in there, too. So I'm sure you're gonna know what I'm going to ask. But, so in our state, you know, we are seeing the numbers climb, but yet, we're asking to open the doors at the schools. And so there is this, this catch-22 of the fact that the schools are saying, you know, are being, what I believe is probably one of the safest places right now. They're doing a great job of keeping the students safe. And there's been a lot of talk of, you know, staying in this hybrid, remote model and not moving towards a full in-person. But how do you go to a full in-person, when your governor is then saying, “We're shutting things down. We're going in these different directions, we're moving. You know, we were red, now we’re green.”? So how do you how do you work with that, when, in one aspect, you're saying the schools are safe putting the kids in, but then on the other hand, you're shutting down other things? And I just feel like it's a little bit of a catch-22. Thanks.

NUZZO: So I mean I understand the communication challenges about that. I mean, I do think that those things are not inconsistent with each other. I mean, I would like to see more things shut for the purposes of ensuring that we can reopen or keep open schools. I think that should be a priority, all over. And, you know, there are important considerations. And so like, where I live, they announced in July that they were going to not open schools in person. And then our case, numbers just kept climbing. And then we kept opening things and then come the time when they thought they would start remote learning, by the way, our case numbers were way too high. So there were there may be tradeoffs, I mean, reopening schools is easiest in that prospect in the context of stable or declining case numbers. And if you need to close things in order to get to that point, then I think that's an important priority for communities because it is very difficult for working parents. Remote learning is by no means a substitute for in-person education, particularly for the youngest learners. And I think that's where you're starting to see a number of places like Michigan, for instance, implementing more restrictions, but prioritizing K to eight education, and making sure those kids who are least able to learn online are able to receive in-person classroom education. But I also think it requires a lot of communication and working with the teachers and so that they have input. I know in a lot of places battles with the unions have prevents the schools from reopening. And I can tell you as a mom, I want my kids back in school, I know that they're being in school will only be beneficial if their teachers don't feel like they're there under duress. And so they need to have input and they need to feel comfortable with the protocols. Otherwise, I think some of the benefits of the in-person instruction will have eroded.

FASKIANOS: There's a chat about are there specific mitigation measures that you think ought to be in place across the board protect teachers, students and their families in schools?

NUZZO: Yeah, so I mean, so far, what the data are showing is that it is possible to reconvene school safely, but there are some requirements. And the first easiest, not easiest, but the first highest impact requirement is having, you know, stable or declining case numbers. So if you're in a place where the case numbers are accelerating, and they're accelerating, you know, possibly beyond control, then that's just going to make it harder. But once you know, you're at that point where the case numbers have stabilized, and again, it may make mean making tradeoffs in the larger society about what will stay open to get it to that point. But once you get to that point, I mean, then it becomes the kind of layered approach that we always described. So masks, physical distance, trying to improve ventilation to the extent possible. And, you know, trying to limit the number of people who are exposed to each other throughout the course of the day or the week. That kind of cohorting helps reduce the chances that if a case did come to school, it kind of caps the total number of people who could be exposed to it. There's not a whole lot of evidence that in the context of safety protocols and schools that we're seeing a lot of spread in schools. We are certainly seeing spread in school populations in extracurricular or social activities around school. So that's another important factor that we need to consider. You know, if they're the sports practices that are going on without protection, or the parties or things like that, then that's really where we've seen a lot of the cases. In the context of like the walls of the school, if we are able to keep masks and keep some level of distance, and reduce the number of students who interact with each other. No, I think there's a reasonable hope that that's a fairly, fairly safe prospect.

FASKIANOS: And to that end, would you say that, that closing park playgrounds might help stem it? Because that's sort of an extracurricular.

NUZZO: I'm not worried about playgrounds outdoors. It's mostly the indoor environments that we worry about. Yeah, I mean, I think I'm less worried about playgrounds, I think kids need some time to release physically, it's more of the indoor environments. I will tell you one challenge has been schools that are trying to make that like six foot distance between students have sometimes chosen to do hybrid models, whereby they only bring students in for some day of the week, in an attempt to reduce the total number of students. I think it's possibly okay to do that, but the worry that I have is that actually in doing that, you could increase the risk of transmission just because of what the students will be doing when they're not in school. And if it means that they're going elsewhere, and they're exposed to larger networks of people, that could actually increase the risks. So personally, I would, I would compromise on the absolute physical distance. If you were worried that in doing a hybrid model, you were increasing the number of people to whom a student may be exposed on the days that they're not in school. And that's really going to be community dependent.

FASKIANOS: Thank you. Let's go next to Patty Bacon.

Q: Okay, I'm Patty Bacon. I'm deputy mayor of Brookings, South Dakota, we have a population of about 20 to 25,000, plus another 10,000 college students. We host the largest university in our state. And so that is added distress to our problem solving. But I did want to share because we have had some pretty good success. We were the first community in the state to take any initiative. Right in March, we shut everything down. We did a total shutdown for about six weeks. And then we very gradually reopened the community. And then we saw a spike in August when the students returned. And so we went back to a partial shutdown. But I'm I didn't get the name of the--I think it was the first person who spoke, but as I said that she their community couldn't find a legal way to do this. And I don't know they probably already explored it. But we were able to do it by calling it a public health emergency. And that gave us (the municipality) the power to enforce these initiatives. And the state couldn't override as right as on that. We've also put together phased protocols. So depending on the number of cases, if they continued, if they rise again, we will go back in in very careful stages to further shut down if necessary. But we've wanted to keep our local businesses open as much as we can. And after that initial shut down, we have. But we were also the first and only community in the State of South Dakota to put a mask initiative. And for those of you in local government understand what it's like to have 250 angry people yelling at you for a couple of hours. And we opened ourselves up to that more than once and let everybody have their say. But we did go ahead and put the mass mandate in place and it is working. We still have one of the lowest rates per capita in our state. So it's been hard, it takes thick skin. But this is an exceptional time when we all have to have a lot of courage to get the job done.

NUZZO: Kudos to you. That's really inspiring to hear. Thank you. Thank you for all your hard work. That's really, really fantastic news.

FASKIANOS: Let's go next to Ire Bethea. Please excuse my mispronunciation, so you can correct me when you unmute yourself.

Q: Ire Bethea. What I have to say most people have already said it. Jennifer, she broke it down very good and a couple of other people. But here in Ocala, Florida. I am a councilman here in Ocala. And we did a mask mandate and we was all overran, bombarded by those that didn't believe in the mask, accelerate cetera, but we, we stood our ground. And I do believe that it’s actually working. You know, a lot of time with the mask mandate, there's not a lot of teeth that you can put in, because you're trying to work with, you know, the small businesses, etc, etc. But I do see in our community, we have about 57,000 people in the city of Ocala and 370,000 in the county of Marion. And I think that is working, but all over Florida right now, you know, we’re seeing rising cases. I am a survivor at this time of COVID. I spent twenty-six days in the hospital. And ma'am, Jennifer, like you said, you know, with your local officials, having people tell you their story. You know, I have shared with many, many groups of people about you know, how COVID affected me I was in hospital twenty-six days, walked out about thirty-five pounds lighter, and was eating every day, three days in three meals a day, you know, etc., etc. But ma'am, we have to come together in this country, we got to work as a unit, we got to do the masks, we need to do the social distancing, and we need to sanitize. Those are basic practices that we can do as a human being, if not for ourselves, for our fellow man. And we just got to do it. This is our season, it's time for us to work together to make to try to rid ourselves of this pandemic. And I don't think this is an overnight process. But we got to take those baby steps and get there. And basically, that's all I have to say, ma’am, because like I said, everybody has kind of shared, but I'm a living witness. You can survive it. If it's caught in time. And you got good doctors and I was just blessed. And I'm doing so much better now. And I'm getting stronger all the time. That's my testimony.

FASKIANOS: Thank you.

NUZZO: Really moving. I really, really appreciate hearing that and learning from you.

FASKIANOS: And there is someone in the chat talking about politicizing this health issue is not helping anything we need to be united together just like we did during, it's very interesting, during the 911 crisis--that we worked across political lines. She says there have been many stories about death certificates that were written to indicate COVID instead of actual cause, as you know, this idea that hospitals are getting money extra money when the cause of death is listed as COVID-19. Maybe you could just dispel that myth. I think it is a myth.

NUZZO: So one of the things that I am involved with outside of the Council is the Johns Hopkins COVID Coronavirus Resource Center. So that's the global map that has got billions of eyeballs on it every day. It's what news services used to know how many cases we have. And I also used to be a local epidemiologist. So I can tell you with much certainty that our COVID case numbers and our COVID death numbers represent underestimates of how this virus has affected our communities, gross underestimates. And the reason is in order to be really counted as a case, and to some extent count and counted as a death, confirmed death, you need to have been tested. Now there's some possibility to list as a probable case, or a probable death if you haven't been tested, but not all states actually even report those data. So many states could and don't. And so they're not capturing those deaths. And one of the reasons why we know that COVID is not being overly reported in excess of what we think is actually happening is there's this epidemiologic concept of excess deaths. So often in places of the you know, the world where we don't have great surveillance, one way to tell how an event has affected us is to look at the number of deaths that we see in a time period and to compare that to previous years of the same time period. And what study after study in various environments have shown is that the excess deaths that we are seeing now far exceeds what the COVID reported deaths are meaning that more people have died this time period than in previous years of the same time period. Now, not all of those are going to be direct COVID, but some of them are. And the other ones are probably COVID related, maybe the people who couldn't get to the doctor. I work with a lot of clinicians at Johns Hopkins Hospital, and they have told me that the number of heart attack patients that they saw in the spring, dramatically decreased. And they don't think it's because people weren't having heart attacks. They think that people just weren't coming to the hospital because they were scared or didn't think they should, or etc. So the COVID related deaths, which is not directly caused by COVID, that don't show up in our COVID case numbers at all, but do very much go into those excess deaths. I mean, that's also another way that this virus has harmed us. So I can tell you with lots of certainty that the numbers are an underestimate.

FASKIANOS: Right. And I, we've so many raised hands up, but there are two that came up in the chat that I think you could, you know, answer pretty quickly. This question to the extent that you know now of the two vaccines that are seem to be going to FDA for approval, do we know how long they will be effective for? And then if you have had COVID, do we know if what the immunity is? Or is that vary from person to person?

NUZZO: Yeah, so we don't know. I mean, we do think it is possible to get COVID again, but how frequently that will happen? We don't know, and what that second infection will look like? We also don't know. So I think you should take away from that. That is that if you've had COVID in the past, don't assume that you're safe going forward. I think there is a hope, though, that you'll have some level of immunity. Again, it may depend on how severe your first infection was. But we basically don't know. So people who are saying I know some political leaders right now are saying that like you're immune, you're great, you know, go out and live freely. That is really bad advice, because there's no evidence that that's possible. And it's also no evidence that you won't spread it to somebody else, who could very much have a severe illness. So important, even if you've had it in the past to protect yourself. In terms of the vaccine, I mean, all we know right now about these vaccines, the good news is that they seem to prevent clinical disease and a high percentage of people who received it over 90% for two of the vaccines that have been reported to date, but that's clinical disease, that's symptomatic disease. We don't know if it prevents infection, chances are it won't. So that could still mean that you could get infected and spread it. Which is why people are saying listen, it's good news. Having a tool that could prevent keep people out of the hospital, keep people from dying is a win. But it doesn't mean that it's going to fully protect everybody. We still don't know how it's going to perform in all groups. We don't know how it's going to work in kids. There's just many other unknowns and so cautious good news, but still many, many more things to learn.

FASKIANOS: Thank you. I'm going to go next to Mary Dickinson.

Q: All right, great. I'm Mary Dickinson. I'm a brand new city council member. I got on council just in time did not January of this year. 75 years old, and also a retired schoolteacher. So yes, the schools, I feel that very much. So every day I worry about the depression of the kids, and the frustrations and heartbreak of the teachers not being with those kids. This is one of those side effects. But I'm really grateful, by the way, that I'm in Washington state, thank you very much. The beginning of this pandemic was right here in my county, excuse me, no, I'm not sick. Right in my county, and I'm very proud of our governor. But even living on the Puget Sound area of Washington State, there's still pushback on the use of masks, social distancing. And so I start every council meeting that I get to say something, I tell people wear your mask, social distance, wash your hands. And we also have on our council, the CEO of the county health district. So thank you very much for being on our council. We are seeing a spike like everywhere else. And I am so grateful to listen to what's happening across this country. I have a grandson in second grade in Texas, and he is learning virtually, and it's really a struggle for those kids. So anything that can, what I see is that school should be first priority. I take that as my most important message here. And I want to know, how do I make sure my council sees that as first priority and not small businesses, restaurants, bars and gyms? Places like that, of course right now are all shut down by our governor. Thank you.

NUZZO: Yeah, it's um, it's it's quite difficult because obviously, the  interim economic harms to the restaurants and bars, gyms are quite obvious, with the long term economic harms of the loss of learning that our children have experienced so far, are really quite staggering. And, you know, there have already been studies suggesting lifelong earning loss as a result of the loss of learning that's occurred today. My son is also in second grade, particularly, it's a terrible time of life to spend your day on a computer. So, you know, it's it is a tough argument, I realized when the benefits of returning kids to school, from an economic standpoint are longer, although, you know, working parents, obviously, are really struggling with these current situations. And I know anytime I talk about schools publicly, I usually get a flurry of emails from deeply worried moms who are not only worried about their own children, but about children who have access to fewer resources than they do. And I too, you know, worry about this. Just seeing how difficult it is to kind of keep our family running in these circumstances and to think about families that don't have the level of resources that we do. It's it's very difficult.

FASKIANOS: Let's go next to Ellen Smith.

Q: My question has to do with civil liberties. I'm in Oak Ridge, Tennessee. City council member. And this is a state that is completely open for business these days, we don't have any shutdowns. Masks are being required in some parts of the state. Cities have been told that we have absolutely no authority to do anything. So we're dependent on other entities to act on our behalf. And the folks who are in a position to make decisions, one of their reasons for not doing anything is a concern that restrictions, mask mandates and restrictions on businesses violate civil liberties. Now, I can argue about that myself. But I'm wondering if there's any kind of analysis that's being done at your level, to deal with those kinds of arguments.

NUZZO: I'm not a lawyer, but I know a lot of public health law experts. And I will tell you that I think there's fairly solid legal precedent about when the public's health is at stake, that that definitely can Trump concerns about individual liberties. There have been many, many historic cases that they would cite as sort of precedent for that. So I will just say so, you know, my legal colleagues would would be able to give you a stronger argument on that front. I will just say, you know, I think what we're seeing right now, is that even some of the staunchest opponents to these restrictions when faced with rapidly accelerating case numbers and really hospitals on the brink, we see them do things they say they would never do. You know, close restaurants and impose mask mandates. And, you know, even some of those measures can have fairly, I think, consequential impacts on the case numbers. I just hope it doesn't take getting to that brink and the lives lost, accumulating until then. But I think at some point, even the staunchest opponents are going to have to face reality and, and make changes.

FASKIANOS: Thank you. Let's go next to Linda Cherry.

Q: Good morning. My name is Linda Cherry, Murray city councilwoman for the city of Murray, Kentucky. Population about 17,000 with another 10,000 at Murray State University. My question is, I get a lot of criticisms and complaints from my constituents that tell me when they do go out to stores to shop, they have their signs on the door that say you must have a mask on in order to enter the property. And yet once they go in, they encounter people that are in the store that are shoppers that do not have their mask on. And I guess my question is, is there something our city can do that will I don't know what the word is force our business owners and our shop or shopping stores to enforce their own mask mandate that they have listed on the front of their door? I feel like this is where a lot of our contagious people are going and I feel like they're spreading the coronavirus this way by not wearing their mask or not even wearing their mask properly, having their mask dropped down just above their upper lip so that they can breathe freely through their nose.

NUZZO: And are they, is it a requirement at the city level? Or is it just being imposed by businesses?

Q: I believe it's something that businesses started some time ago right back with the governor's mandate, the city has not made a mandate.

NUZZO: I know some places have used like call-in lines for people to call and issue complaints. And then usually there's some level of follow up with the business. I mean, I think if it's not a requirement of the business was a little bit tough, but to know that their customers are complaining they may want to know that, particularly now, nobody wants to sort of lose a customer. I really think we have to frame this as this is our path to freedom and not a restriction of our freedom. This is what's going to keep our businesses open. And nobody wants to see a closure. And just kind of a problem. That pragmatism.

Q: Yeah, if they understand it's advantageous to them to do this, to enforce their own mask mandate, then more people will come into their stores because they will feel safer there. I just don't know how to get that out to the business owners?

NUZZO: Well, I wonder if they even know that people are calling to complain. I mean, that just might be one way to start the conversation.

Q: Yeah, that’s possible. And there is a number we can call. It's called Kentucky safer. And I've called it myself. And I hear other people that say they've called the number and they don't get, I guess what they expect to get as far as their response to their complaint.

NUZZO: No, we've been trying to kind of prevail on people, kind of coerce some behavior change by trying to make data available. And I'm just wondering if there's some enterprising person if those data are public, of where the complaints are being lodged, and they could just if there were a public database of what businesses were getting complaints about that perhaps that might encourage more adherence, sort of bad advertising. I mean, nobody wants to tarnish business's names.

FASKIANOS: Jennifer, are there governors or states that you would point to that are using federal COVID-19 relief dollars to do--using it for education and outreach and partnerships with the business community regarding prevention and mitigation, messaging and practices? It's something that was written in the chat. And we also had somebody from Texas asking, you know, it's not mandated at the, at the federal, I'm sorry, at the state level, and so they can't say you have to wear a mask. Are there other less, other measures that could be sort of put into place that wouldn't be seen as you know, an infringement of civil liberty? Or is the mask really is the best thing?

NUZZO: I mean, nothing is so. So I actually don't know the answer about what places are using money to pay. But it seems to me if you could, that would be a really important intervention. Because I do think this is going to take a partnership, because even if there are requirements, requirements alone, mandates alone do not result in--you do not necessarily assure compliance. So it is going to be both carrots and sticks. And  I think we need to look into more carrots for sure. In terms of sorry, there was a second part of that question.

FASKIANOS: It was a different question from Texas. It's, there's not going to be any shutdown, what can we do at the state and local level, knowing there isn't an option for aggressive containment?

NUZZO: Right. So I mean, first of all, I mean, one thing that we've always said is that just because it's open doesn't mean you need to go and allowing people to understand what are the highest risk places. And they are places where indoor environments that have poor ventilation, where you can't maintain physical distance and wear a mask. And that's why restaurants and bars tend to float to the top, because it's hard to comply with, with those recommendations. And that's why you'll see in a lot of places, if they're not even doing full closures or reducing occupancy, sometimes they actually close at a certain hour. In part, because the thought is that people are less compliant with the recommendations to kind of keep their masks on when they're not drinking or eating and, you know, keep their physical space. So there's always the if it's just because it's open, doesn't mean you need to go. There's also encouraging people, pointing them to alternatives. And, you know, nobody wants to see a restaurant or bar go out of business. But if there are options to encourage people to do take out, to try to like point a path forward. That's not just don't leave your house, because I think that's a very, that’s not a sustainable message. So if there are ways to, you know, create more space for I know, one of where I live, the one of the towns actually went up shutting a street so that the businesses could--the restaurants could create more outdoor dining options so that people could go and support the businesses, but in a safer way. It's not--none of this is perfect. I mean, really, the safest thing is to stay home. But, you know, how long can we do that for? So trying to find alternatives to point people to as much as possible. Again, we don't have to be 100% compliant. Here, the goal is to reduce transmission to the point where it's not so rapidly accelerating so that we do see even a slow simmer would be much better than what we're seeing right now, which is basically a vertical climb.

FASKIANOS: Great, we have two minutes left. And there are so many raise hands and questions in the chat. Maybe it might be helpful. You talked about wraparound services, and this was in the chat. How would a locality or state implement wraparound services in their community? What are some of the things that they could do?

NUZZO: So this is a tough thing without additional resources. I will acknowledge and I think this is one place where we need to take it to the national conversation. This has been missing in our U.S. response to this virus and other countries have done this. And they have they see the benefits of this; this is in their economic best interest. And so, if you're talking to your elected officials who are you know, in Washington, as they negotiate the stimulus, this is a really important point to get across. Which is that we need to reduce the disincentives and help people comply with the public health orders. I mean, in my view, that's far preferable paying somebody who is sick to stay home, than to shut down an entire state. So we need to make those arguments. But at the local level, let's say if you don't have a budget for it, which chances are you don't, you know, I think it's also about connecting people to the services that already exist, and to the extent to which they have and that may not all be government services. It may be non-governmental organizations in the community. And just seeing what's possible to help people who require help. Particularly, you know, maybe some faith organizations that may be able to to work in the community and just trying to take stock of what the social services are that exist in the community, governmental and otherwise, that could potentially help and link people who need who need those services to them.

FASKIANOS: Great, thank you. I know we had so many questions. And we will continue to have this conversation and actually pull from some of their questions to continue to dig down on some of these issues that you've raised. Jennifer Nuzzo, thank you very much for today's conversation. It's so great to have you with us at CFR now and the work that you're doing at Johns Hopkins, the tracker is so fantastic. So it's a great service. And we look forward to having you back to for continuing updates on this. You can follow Dr. Jennifer Nuzzo on twitter @JenniferNuzzo. And we will send you all a link to the webinar recording and transcript so you can review it again share it with your constituents, etc. And again, please do reach out to us, let us know how we can support you other topics you want to cover specific issues to drill down on as it relates to COVID-19. You can send that to [email protected]. So, as Jennifer said, thank you for all you're doing in your communities. This is hard for all of us, and we just have to continue to chip away and try to get this under control.


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