Thread by @JeremyKonyndyk

I have been highly critical of the administration's COVID19 response, and with sound reason - they have left us perilously unprepared.

But at this point we are where we are. Accountability will come someday but first we need action. Here is an attempt to outline priorities.

And I say with profound regret that we cannot rely on federal leadership to carry us through this.

If you think this overly harsh, I refer you to the folks at @nro, with whom (to put it mildly), I rarely agree on anything. But they're right on this: nationalreview.com/2020/03/presid…

So this will be won or lost by leadership at state, local, civil society, and private sector levels. Look to mayors, governors, community & biz leaders, and fight this city by city.

What we're up against: a trajectory that puts US <2wks behind Italy.

https://twitter.com/MarkJHandley/status/1237119688578138112?s=20

The core objective, as I argued over weekend, is slowing spread enough to buy time for hospitals to stay on top of critical cases. Need a multi-track strategy to suppress the outbreak while expanding clinical bandwidth to treat. That's the ballgame.

https://twitter.com/JeremyKonyndyk/status/1236704435855818757?s=20

This is past the point of urgency, as @mlipsitch argues in this grim but compelling thread.

Wuhan-level spread here would overwhelm our hospitals, and undermine intensive care for *everything*, not just COVID. That's already happening in Italy.

https://twitter.com/mlipsitch/status/1237352858380632064?s=20

So - how to achieve this? Need strategies that adapt broad shared priorities to local conditions and local epidemiology.

We won't have one monolithic US outbreak. We will have a series of interconnected locality-level outbreaks, each with their own dynamics.

Unifying idea everywhere is you have to trigger measures that seem too extreme for the current circumstances.

Far easier to overreact and dial back than to underreact and have to catch up. Catching up becomes disproportionately harder the longer you wait.

https://twitter.com/pwnallthethings/status/1237581473915367424?s=20

Priority 1: Understand the epidemiology.

It is hard to fight what you can't see. Being at points 1, 2, or 3 on this curve has huge implications for strategy options, even if those points only differ in time by a matter of weeks.

https://twitter.com/JeremyKonyndyk/status/1236704438112473090?s=20

How you work to flatten the curve depends on where you are on it. But without aggressive surveillance and testing, it's hard to know that. So understanding the epi is the foundation.

Priority 2: Flatten the curve.

The further you are up the curve (point 3 vs point 2 or 1), the more aggressive and widespread the measures must be. At point 1, contact tracing and targeted quarantine are relevant; at points 2 and 3, they can't keep up.

https://twitter.com/rebeccajk13/status/1237035562093158411?s=20

So as spread increases, contact tracing and targeted quarantines should be de-emphasized in order to focus on macro social distancing and promoting behavior change.

@cmyeaton has a good thread suggesting social distancing made a big difference in Taiwan:

https://twitter.com/cmyeaton/status/1237409243126312960?s=20

Large gatherings, conferences, events, parades should be suspended. There is still debate about schools closures given uncertainty about how COVID behaves in kids. But halting large events is a no-brainer. And yes, this most likely mean playing March Madness to empty stadiums.

You - average citizen - have an important role here. Begin promoting social distancing. Minimize travel. Ask questions of your schools and workplaces (at our kids' school we found the kids weren't getting time to wash hands before eating; we complained loudly).

Make noise.

Call on public leaders to cancel events. Stop going to those events yourself (I'm skipping a long-planned 10k this weekend). Vote with your feet.

Priority 3: Targeted protection for high-risk groups.

Public health officials should review vulnerabilities and monitor for cases at every nursing home, prison, senior community.

Staff working travel screening should be refocused on this. That's a sideshow; this is main stage.

But don't leave this to public authorities. Support this in your own community.

If you have loved ones or neighbors who are high risk, ask if there are ways you can help them in minimizing their forays beyond their home.

Protecting the high risk means fewer people in hospital.

Priority 4: Protect hospital bandwidth. The above priorities, if done comprehensively, can delay spread and reduce peak volumes. But depending on how late they are triggered, it may not be sufficient.

Also need to protect/expand hospital capacity.

Must reinforce training, PPE, and infection prevention to minimized damaging exposures of health workers.

And must find creative ways to expand ICU capacity and plan for in extremis patient volumes.

Excellent overview here: centerforhealthsecurity.org/cbn/2020/cbnre…

Priority 5: Mitigate economic shocks and other second order impacts. Many social distancing measures have economic disincentives - e.g. it's hard for gig or hourly-wage workers to decide not to work, or decide to stop interacting with customers. Need targeted econ help.

Priority 6: Clear risk communication. @EIDGeek is the expert here. Build trust through transparency over time. Don't hype the risk but don't downplay it artificially. Provide clear, actionable guidance that validates people's fear while channeling it into action instead of panic.

The specific tactics under each of these priorities will differ by community, depending on where they are along the curve and other local factors. But these are priorities that local leaders and local citizens can begin meaningfully taking forward.

Let's do this.