Analysis

Where public health and public policy meet and part ways

By , Daily Memphian Updated: April 09, 2020 9:31 AM CT | Published: April 08, 2020 3:55 PM CT

Just about every time he talks about COVID-19, Memphis Mayor Jim Strickland says the decisions he and other local leaders are making about battling the pandemic are made based on facts and the advice of public health professionals.

As testing locally ramps up and the appeals for social distancing to “flatten the curve” become a mantra, those leaders are relying on a scoreboard of sorts showing the public how many people have been tested in the county, how many tested positive and how many have died from the virus.


First local COVID numbers on race confirm disparity in virus spread


It’s a way to have citizens feel that difficult goals can be met – let them see progress.

The challenge is that what health officials are focused on – healing the sick and stopping the spread of the disease as well as limiting the impact on hospitals so they do not become overwhelmed – does not always get at the question of what is best for the entire community beyond the immediate and necessary objectives.

Memphis has been slower than other cities and states to ramp up the number of people tested, which most experts say is crucial to determining the scope of the pandemic. Local health officials have been focused on the number of positive results.

Shelby County Health Department Director Alisa Haushalter, until very recently, was adamant that increasing testing was not important. “I’ll use (South) Korea as an example,” she said less than two weeks ago.

“They did mass testing. Only 4% of those were positive. That means 96% of the people tested did not need testing,” she said last month on the WKNO program “Behind The Headlines.”

She also said in another interview that testing everyone who wants a test would waste medical supplies.

“The more critical piece is we know the individuals who tested positive are spreading disease in our community,” Haushalter said. “That number is significant regardless of the denominator.”

As a result, for weeks she refused to release basic information other municipalities and states were releasing, including the total number people tested. The county has only released the number of people hospitalized and how many are in intensive care or on ventilators on a few isolated occasion. It is information available daily in states such as Louisiana, which has more positive cases and deaths than Tennessee.

Meanwhile, the experts are feeding that data and other data into models that inform how they will change the measures that from the beginning last month in Memphis have always been a series of steps.


Questions about race and locations of COVID-19 outbreaks gain attention


“Social distancing will not only flatten the curve, it will stretch it out,” city chief operating office Doug McGowen said Tuesday of the complexities of trying to forecast the immediate future with numbers that can change dramatically in a short period of time.

FiveThirtyEight, the statistics and analysis blog by Nate Silver, has reported at length about which statistics in COVID-19 testing are relevant and why.

In an April 4 post, Silver said testing numbers in and of themselves aren’t very useful without knowing how tests are being conducted. The influential blog looks at statistics and their analysis in politics as well as sports and other police areas.

“The data, at best, is highly incomplete, and often the tip of the iceberg for much larger problems. And data on tests and the number of reported cases is highly nonrandom,” Silver wrote in the post. “In many parts of the world today, health authorities are still trying to triage the situation with a limited number of tests available. Their goal in testing is often to allocate scarce medical care to the patients who most need it — rather than to create a comprehensive dataset for epidemiologists and statisticians to study.”


Local COVID-19 effort takes critical look at optimistic virus modeling


Without knowing why health authorities are testing, Silver warned the wrong conclusions can be drawn.

“You don’t just run the risk of being a little bit wrong: Your analysis could be off by an order of magnitude. Or even worse, you might be led in the opposite direction of what is actually happening,” he wrote. “A country where the case count is increasing because it’s doing more testing, for instance, might actually be getting its epidemic under control.”

“Alternatively, in a country where the reported number of new cases is declining, the situation could actually be getting worse, either because its system is too overwhelmed to do adequate testing or because it’s ramping down on testing for PR reasons,” Silver wrote.

From the outset, the Shelby County Health Department had numbers of how many people were being tested but wouldn’t reveal those numbers even though it and other public health experts in the city were reviewing them daily.

Haushalter instead said the more important numbers were those who tested positive for the virus because the unknown number of those being tested was a population that was limited to those who were symptomatic and had been referred specifically for testing by doctors.

When the testing numbers became part of the daily public briefings and press releases, there was less talk about the positivity rate. Through Tuesday, a total of 9,913 had been tested by the Health Department’s numbers with 897 confirmed case in the county for a positivity percentage of 9%.

Before the total tested was factored in, estimates of the percentage ranged from 3% to 10%. That’s among the health professionals who knew how many had been tested but had legitimate questions about who wasn’t being tested and why they weren’t being tested.

Testing at the city’s drive-thru center at the Fairgrounds operated by the University of Tennessee Health Sciences Center remains for those who say they are symptomatic and make an appointment. But the testing effort across the city and county is now poised to expand beyond several hundred a day.


Task force aims to test 1,000 a day, whether they can pay or not


And that is where the lack until a Wednesday, April 8, briefing of some kind of a breakdown by race of those tested and those who test positive joins hands with not only the city’s historic racial divide but also the evolving political realization that equality isn’t equity in Memphis.

At his Tuesday White House briefing, President Donald Trump acknowledged there is a disparity in what the COVID-19 numbers show so far – African Americans are a disproportionate part of the pandemic.

Trump followed the next day with a call for more testing.

“It’s showing up very strongly in our data in communities and we are doing everything in our power to address this challenge and provide support to African American citizens of this country,” Trump said Tuesday. “It’s become disproportional. They are getting hit very, very hard.”

Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases and Trump’s most visible advisor, followed him to the podium. Fauci followed with why race matters in the growing amount of data and the competing models the data generates.

He called the racial disparity in the COVID-19 numbers an “exacerbation of a health disparity.”

“We’ve known literally forever that diseases like diabetes, hypertension, obesity and asthma are disproportionately affecting minorities -- particularly African Americans,” Fauci said, noting that those conditions are often contributing factors cited in COVID deaths.

“They are just those various entities that are prevalent in the African American community,” he said.

So are mass incarceration, food deserts and other forms of disinvestment in communities that make up the city’s racial majority.

Leaders of the social justice group MICAH – Memphis Interfaith Coalition for Action and Hope – had praise for the local pandemic efforts around mobile food pantries for those communities as well as mobile testing efforts Strickland announced earlier this week.

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MICAH also called for other moves like a 90-day moratorium on evictions and foreclosures and reporting late payments to credit rating agencies as well as a case by case review of clearing the county’s prisons and jails and other correctional facilities. Other points in the plan include making sure advisories and information on the pandemic and local measures and programs are made available in different languages.

“The more that the resources can go out as opposed to people having to put themselves in danger is something that I think we would stand for,” said Meggan Kiel of MICAH after talking about the lack of reliable public transportation to get those from all communities to testing and medical care.

Earlier in the day, Haushalter was asked about improved public transportation to get to testing and said health officials have serious reservations about those who fear they may have the virus crowding together on buses to get testing.

It’s another indication that the pandemic has found the touchstone of long-standing inequities in Memphis and has also forced public health experts as well as activists and agencies to think about those inequities in new ways.

“We know that this COVID-19 crisis has only exacerbated the issues that our three task forces … have been working on up to this point,” MICAH president Stacy Spencer said Tuesday.

“Instead, it has magnified the inequities in our societies, laying them bare for all of us to see,” he said. “Who can easily continue their education with devices and wi-fi and who cannot? Who is most at risk of losing the roof over their head and who is not? Who is left in crowded jails because of their inability to pay and who is not?

As that has happened, an ambitious plan by Shelby County Mayor Lee Harris to infuse the Memphis Area Transit Authority with a stream of recurring county funding that was an uphill political prospect at best seems forgotten.


History shows budget problems predate pandemic, Burgess says


Urgency for now seems a resource devoted completely to COVID-19. Some elements of the city’s new activism of the last five years seem hesitant for now to criticize the effort. Some of that is a function of the movement of some on the city’s front lines of change to elected and appointed office.

Question? Yes. Criticize? At least not without a lot of qualifications that separates the good intentions of the measures from the fear that after the pandemic the urgency will go back in the closet.

Public health and public policy are looking at different parts of the same pandemic at times while singing from the same hymn book.

The public health side sees wasted supplies if there is too much testing.

The public policy side sees too much uncertainty that creates non-medical problems that masks and washing hands won’t solve.

Public health sees pinning too much hope on snapshot test results and numbers.

Public policy sees an economic recovery stalling past the reopening because people don’t feel safe even if medically they are safer from the virus.

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Topics

coronavirus Alisa Haushalter Doug McGowen COVID-19 testing
Bill Dries

Bill Dries

Bill Dries covers city government and politics. He is a native Memphian and has been a reporter for more than 40 years.


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