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Q&A: UW-Madison epidemiologist Malia Jones on what could and should come next in COVID-19 pandemic

Q&A: UW-Madison epidemiologist Malia Jones on what could and should come next in COVID-19 pandemic

Malia Jones

UW-Madison epidemiologist Malia Jones poses for a portrait at her home during the COVID-19 pandemic. 

Since UW-Madison epidemiologist Malia Jones first shared her thoughts on the novel coronavirus pandemic in a social media post that went viral, life as many people knew it has completely changed.

Jones also learned that systems she thought were in place to respond to a pandemic — such as stockpiles of masks — are broken.

“We have always known something like this would eventually happen. It's kind of a part of the natural world,” Jones said. “I was really disappointed a couple weeks later when it became obvious that those responses were not happening. … We were really unprepared as a nation to respond to a pandemic.”

COVID-19, the disease caused by the virus, has infected 1,730, hospitalized 461 and killed 31 across Wisconsin. In Dane County, 246 people have tested positive for COVID-19, and four have died from it. Schools, businesses and public places are closed. Unemployment claims have skyrocketed. Gov. Tony Evers ordered the state to stay at home.

One week into the governor’s “safer at home” order, Jones is seeing some positive movement but more data is needed for a clearer picture.

In the long term, she said, a vaccine is the answer. But for now, more testing and the capability to trace who an infected person may have been in contact with is a way to achieve a “more conservative approach to social distancing.”

And if it seems like the state of the pandemic and guidance on practices to stay healthy are changing constantly, Jones said, that’s because they are.

“We are learning a new thing every day about this disease and that is causing a lot of people some anxiety and feelings of mistrust,” Jones said. “I think that people really need to understand that science is working extremely fast, faster than I've ever seen scientists work.”

This interview was edited for clarity and brevity. For the full interview, listen to this episode of The Madsplainers podcast.

When you first came on our radar, it was in part because you'd written this Twitter post a few weeks ago that went viral. Last weekend, you posted an update in which you said some of your initial assumptions had been wrong. Can you tell us what went differently than you had expected or imagined? 

I think that I made a couple of assumptions that a lot of epidemiologists made. And the main one was that we could see the data coming out of China that this was looking pretty grim like we had a new disease on our hands and that it was spreading around the world. That became obvious sometime in February. By the end of February, it really looks like it was a pandemic situation and that we were all going to be dealing with COVID-19. At that point, I think, just a matter of time before it came to the United States.

It was March 5 that I wrote an email to my friends and family about what I saw was coming. What I expected to happen was ... after 9/11, we had all these pandemic response plans and supply stockpile plans, and all these things were put into place to deal with something like this. I thought those systems were being activated and that we would be prepared to respond to something like a pandemic. Really, we have always known something like this would eventually happen. It's kind of a part of the natural world. I was really disappointed a couple weeks later when it became obvious that those responses were not happening. We didn't have those plans in place. The stockpiles had kind of been abandoned. We were really unprepared as a nation to respond to a pandemic. Some of the things that I expected to go well really didn't, so our response has been impaired by that.

Could you give examples of what you expected to happen but didn't?

One thing I expected to happen was that we would get some early and really strong guidance from the CDC about what to do. I was disappointed to see that I think the CDC's response was fairly slow. By the time we had really strong national leadership — CDC is who we would expect to get guidance from on things like (when) it's time to issue a shelter in place order — things were fairly well out of control in the United States. If we had had earlier intervention and stronger national coordination, we would have been able to stop the pandemics spread within the United States earlier on. We didn't see that.

Another example is I really fully expected that the United States would be able to scale up testing very rapidly, similar to what South Korea did, and we just were not. We were unable to scale up testing. In fact, we're still waiting for that really critical component of the response to come online. We need to have very widely available, free rapid testing, in order to know who has the disease, and for a variety of reasons, we still don't have that. That was also a surprise.

You introduced us to this term social cocooning, which is your way of saying social distancing. Has it been working? What estimates are you seeing?

There are a ton of estimates out there right now about what's going on in the United States in terms of trying to figure out where are we in the spread of the disease across the country and in the state of Wisconsin. They vary a little bit. There's a good reason why all the different models produce slightly different results, and that's because “model” just means an informed guess. They're really only as good as the data that we can feed into them. We still have really limited data about how many people really have COVID-19 because of the limitations on testing. Some of the variation that you see across the different models comes in because we have to make assumptions about how much has social distancing reduced contact rates between people, how many people really have it in the community who haven't been tested and so on. When you make those assumptions, you can put boundaries on them and see how much it affects your model results. But at some point, you know, you have to go with some reasonable assumptions and see what comes out. The projections do vary a little bit.

It's important to look at where there's agreement across models. There actually is a lot of agreement, saying that, at least here in Wisconsin, we expect the hospitalizations to peak sometimes toward the end of this month or maybe early next month. We're also seeing some initial results in the growth rate of confirmed cases that suggests that social distancing is working. I actually looked this morning and just calculated the difference in the doubling time, which is one way to measure how exponential is the spread of the disease. Last time we talked (around March 15), the doubling time was something like three days, two and a half days. That means every two and a half days in Wisconsin, we had twice as many cases as two and a half days previously.

Now the last couple of days of data, we have a doubling time of seven or eight days, so it is slowing down. I think that is really, really good news for Wisconsin.

Is the curve starting to flatten?

The curve is starting to flatten, and I think we can see that in the data that we have coming out in the number of new confirmed cases over the last couple of days. It's still early days to know how much it's flattening, and whether we're actually reducing the number of cases day over day versus still growing but more slowly. That's because of some of the dynamics of how the disease works. There's this lag time in what we get to see.

Today's new cases that are posted at 2 p.m. this afternoon by DHS are going to be the test results of people who turned up in the ER two to four days ago, because it takes a couple days for the test to get back. You don't turn up in the ER until you've had the disease for about eight to 14 days already. The cases that are showing up in our data today actually were infected before the shelter in place order was even issued. There's this lag time before we get to see any improvement in the cases that are confirmed and posted by DHS. But it's really encouraging that even given that lag time, we're already starting to see some slowing in the doubling time.

That seems somewhat hopeful.

I won't say that we're doing really, really well until the growth rate has gone negative, or we're in decay. I would want to see the number of new cases going down before I said that we're really doing well, and that's a high bar because it is a very infectious disease. We really have to reduce the number of contacts that people have by quite a bit in order to get there and I don't think we've seen that come in the data yet. But over the next week, I hope that we will see that.

Is it still the case that we in this country pretty much only know if somebody has COVID-19 because things were serious enough that ended up in contact with a health care provider?

It's my understanding that that is still the case in Wisconsin, although the number of tests that are being performed per day is going up. That's another sort of math reason why it's a little hard to interpret the data because who is being tested varies over time, too. In general, yeah, we still don't have enough tests to test people who are not sick enough to be showing up at the hospital for assistance in general. Yes, the confirmed cases is still a subset of all of the cases that are out there.

Do you have a sort of an estimate of when we might start to see the number of new cases decline or is that kind of looking into a crystal ball?

It is a little bit looking into a crystal ball because we don't know how effective the social distancing measures have been at reducing contacts. Some researchers are out there looking at the location data from cell phones and from Twitter accounts and other location data sources that come from cell phones to figure out how much have people reduced their movements. That's kind of a hint at how much social distancing has been able to achieve in terms of reducing the contact between people and and from those hints it does look promising. But we don't know how to estimate that number until we actually see the results in the case rate, and it'll probably be another week before we really have a solid handle on how social distancing, how the “safer at home” order has impacted the growth rate of the disease.

[Photos: Madison streets deserted, businesses shuttered as 'Safer at Home' order implemented]

We've been hearing that it's now too late to prevent very serious consequences in the U.S., but I just like to be completely sure that we're interpreting that message correctly. What does that mean about whether we should or shouldn't bother with social distancing?

The real question here is what are you comparing it to? If you're going to compare what we will see over the next couple of weeks, which will be very bad news in the United States, to what if this disease never existed at all, then yeah, we're facing a really serious health crisis and economic crisis in this country. But that's not the right comparison, because the disease exists. We have to compare it to what would happen if we lifted social distancing measures or had never done them in the first place. I just ran some estimates ... that we would have something like 300,000 people in the ICU all at the same time in the state of Wisconsin, which is about 1,500% more ICU beds than we have. It's basically infinitely worse.

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When we last spoke, you strongly urged schools to close. Since then, they have closed as well as a number of other businesses and public locations. We've also seen some pushback and calls to “reopen the economy.” How do you think we should be thinking about these major changes to our lives? What’s the balance?

I think it's this issue of what are you comparing to. There is no denying that this is going to be, and has already been, a tremendous economic shock in the United States and around the world. That's going to have some really negative consequences and probably for a long time. I really feel for everyone who's been laid off and can't work because their businesses are closed, especially small business owners for whom it's really hard to recover from something like an unexpected closure.

That said, the consequences of just going back to business as usual and letting the disease spread through the population are really not something that anyone is willing to accept. If you really look at what that would look like, none of us could accept that. That also has economic consequences. This idea that we should just let everybody get infected and let it burn through our population would result in essentially a complete collapse of a huge sector of our economy, our healthcare system. The number of hospitalizations and deaths themselves have economic costs in that hypothetical scenario, and the impact on the healthcare system, more generally would also have tremendous economic impact that I really think is not acceptable to anyone. We're trying to mitigate what is really a terrible situation here and trying to strike that balance by protecting people's lives and also doing what we can to protect the economy from even worse outcomes.

[Milwaukee's Democratic National Convention delayed until August amid coronavirus pandemic]

What should we expect, after the number of cases hits its peak and we start seeing this decline?

I'm really hoping that what we see is that testing becomes available. We rely on the availability of testing in order to identify who actually has the disease. It's not just going to disappear after a couple of weeks, more weeks or months of social distancing. We're still going to be facing COVID-19 as an ongoing problem in our society. But if we have widely available testing, then we can do this process called test and trace, where somebody gets the disease, they show up in the hospital very ill and then they're immediately tested. Then epidemiologists can ask them where have you been in the last couple of weeks? Who have you been in contact with? Follow up with all of those contacts and isolate just those people and also test them all and see if they have the disease as well.

That's our path to having only some people isolated to contain the disease on more of an ongoing basis. We just can't do that without better availability of testing. Right now we're in a phase where everybody has to stay at home because we can't test everyone. Hopefully we will see over the next couple of weeks or months here as new cases start to decline and testing becomes available, that we'll be able to roll out a more conservative approach to social distancing and have just the people who are actually exposed be isolated and prevent the spread of the disease.

How can we get back to normal without restarting the spread of the disease and how will we know when to start? Is a vaccine the only answer?

In the long term, a vaccine is the answer. There are already vaccine candidates under development, and we really hope that one of them is going to be successful on a fairly short timeline for a vaccine. Ultimately, that would be a great way of managing it. In the meantime, we can't just all stay at home indefinitely until a vaccine becomes available. We have to take some kind of in between approach, which I think means the availability of testing and test and trace.

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When we have that ability to test and trace that requires two things. One is the test. The second is we need there to be few enough cases circulating that it's actually possible to trace all those contacts. Right now, there are so many in the United States that, you know, no one would have the man hours to trace all those contacts. Once we get to a place where the existing cases have kind of played themselves out, and people have recovered or been hospitalized and then recovered or died in hospital, then we will have fewer cases to do that tracing process on. We'll probably still have some spots of outbreak and probably still expect some areas. If there's a second wave of outbreak, hopefully we'll be better able to contain it. Some places will probably see another shut down temporarily while we get things under control again.

Should we expect to see waves with periods of outbreaks and decline in new cases?

That's a very typical feature of epidemics. We would fully expect there to be another wave, but hopefully, we'll be better positioned to control it. In part, because there will be, I hope, fewer cases as part of that wave, and I hope also we’ll just be in a better position to know what to do. We won't wait too long to respond. We'll have the testing and and the tracing capabilities to deal with that. In addition, one of the things about flattening the curve that I think doesn't get quite enough play is that the more time we give ourselves before we face that, the better our treatment options are going to get. It may be that If we have another resurgence in the fall, we're much better positioned to handle those cases and treat them effectively so that they're not so risky. Right now we essentially have no treatment. There's no specific treatment for this disease. Doctors essentially just try and keep patients breathing and oxygenated until they recover. It's just supportive care.

As the pandemic continues, what do you think people should be remembering?

Infectious disease, more generally, is still a real threat to humans. Even in a developed country in the United States, we face thousands of infectious disease deaths every year even without COVID-19 on our hands. I hope that it does bring a little bit more attention and priority to those ongoing issues. A little closer to home, In some ways, it's very heartening to see how people are coming together and being community minded and participating as best they can in social distance and really taking it seriously. It does look like Wisconsin is doing a pretty good job of this from the preliminary data that we have. That gives me a lot of hope for, for humankind in general, that we're capable of working together on something like this.

Is there anything else we should know?

Do you want to get into the morass of masks?


One of the really hot topics that I am seeing in the media and social media right now is masks. I've seen it in a number of different contexts and one version, it goes like: the countries where mask wearing is normative, like South Korea and Singapore didn't have a major outbreak and countries like the United States in Italy, where mask wearing is not normative. We have this major outbreak.

Another version of it is the CDC should have recommended everybody be wearing masks from the get go. There was this MIT study that came out that showed us a sneeze can travel up to 27 feet and that a mask, anything covering your face might be an effective way to prevent those droplets from traveling so far.

My take on this is a couple things. One, I think it's really unfair to come after the CDC for taking the only reasonable position that they could have taken on masks. The fact is we don't have enough masks for our doctors and nurses to wear. Should we have been stockpiling them as a country? Yes, we should have been. There should be billions of masks available in the United States, but they're not. When the CDC said that people who are in really high-risk scenarios, like doctors. should have priority, I don't think they could have taken another reasonable position.

[Until further notice: Madison businesses struggle to deal with the coronavirus fallout]

The other thing to say is that things are changing. That MIT study just came out last week, so nobody knew until that study came out that this researcher found that a sneeze can travel 27 feet. If it feels like things are different every day. They are. We are learning a new thing every day about this disease and that is causing a lot of people some anxiety and feelings of mistrust and I think that people really need to understand that science is working extremely fast, faster than I've ever seen scientists work. We do learn new things every day, so things are changing. The recommendations are changing and they're going to keep changing.

Saying that countries where mask wearing was normative prevented an outbreak from happening and that masks are the reason for that is really misplacing the cause. Singapore in South Korea and Hong Kong were very successful at containing the epidemic because they implemented very early, strong social distancing recommendations. They rolled out very widespread testing really quick. Those are the reasons that they contain the disease. You can find counterexamples to the mask argument. China is also a country where mask wearing is normative and they were taken by complete surprise. Of course, they were first to face COVID-19, and they were unable to contain it even with mask wearing. It's really ignoring the root causes of where the pandemic is in the world to say that it's all about masks. It really is not. It's about the availability of testing and early preventive measures, like social distancing, which is not to say that masks are not worth anything. It's obvious that doctors and nurses need to be wearing them to protect themselves, and we may see guidance come out that everyone should be wearing something over their face when they go out in public in the next couple of days or weeks here.

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