Exploring the Current Condition in South Carolina
A colleague recently directed Forrest to a passage in Jim Collins’ book, Good to Great. Summarized here, the passage describes The Stockdale Paradox, which is named after Admiral Jim Stockdale and suggests a necessary balance between “the faith that you will prevail in the end—which you can never afford to lose—with the discipline to confront the most brutal facts of your current reality.”
Good to Great was obviously written long before any concern about COVID-19, and the book is business “how to,” not a guide to facing a global pandemic. Nonetheless, The Stockdale Paradox is an interesting metaphor for current times. As South Carolina’s leaders begin the process of lifting sanctions and closures across the state, it would benefit us all to remain optimistic that we will prevail AND show a willingness to confront the brutal facts. We are, after all, still in the midst of a pandemic by any objective measure.
We have both been doing a lot of reading, research, and posting the last several weeks. We have leaned on our public health training (more about us here and here) to try and make sense of things and to answer the questions of family, friends, and colleagues.
Trying to process the Governor’s recent decision to begin the reopening process is complicated at best. Attempting to do so while remaining optimistic and hopeful AND being willing to confront the brutal facts led us to put together this piece. Please know we both hold tightly to hope and optimism. We need to get people back to work and get the economy back on track. That’s a given. It should also be a given that we need to do so in a way that protects all of our state’s citizens. This is especially true in a state like South Carolina where large percentages of the population are, for a number of reasons (structural and social), particularly vulnerable. Debating which one of these two goals—restarting the economy and preserving health—isn’t productive. They need not be mutually exclusive.
The ultimate question is, what will it take to “get back” and do it safely? Based on our opinion, the writings and research of many others, and both the White House’s “Guidelines for Opening Up America” and recent testing estimates from Harvard University, here are three questions that should be asked before any decisions are made.
Do we have a downward trend in the number of cases over 14 continuous days?
Can we all commit to continued social distancing (really, physical distancing) and enhanced regulations for employees returning to work—especially those on the front lines?
Are we able to do enough testing?
1: Data Trends
The South Carolina Department of Health and Environmental Control (SCDHEC) website presents data and details from both their public health lab and approved private labs in South Carolina. These data are helpful and important as presented on the site, but don’t really show any clear trendlines. So, we put some graphs together. We relied solely on public and descriptive data reported by SCDHEC on their website and via Twitter (@scdhec). While there are more than 4,000 diagnosed cases of COVID-19 in our state represented in these graphs, remember for every known case, SCDHEC estimates there could be up to nine people with the virus who remain unidentified.
There are three figures presented here, all showing the same data, in slightly different ways. Figure 1 shows the number of new cases each day since the state’s first reported case in early March. These data are reported each day by SCDHEC via Twitter (black line). To help soften curves and account for daily fluctuations, we also have shown a four-day rolling average (red, dotted line).
Figure 2 shows the cumulative number of cases each day since the state’s first reported case in early March. Again, data are a culmination of reporting by SCDHEC via Twitter. While neither of these curves is overly “flat,” they have softened over the last several days. From these views, it’s difficult to say whether our state has reached its peak, but please know that the figures shown here are NOT models. In other words, they aren’t intended to predict the future. We will leave modeling to our infectious disease and epidemiological experts, some of whom are our colleagues.
The most optimistic view of current data comes from total cases reported week-over-week. The seven weeks since the first reported case in South Carolina offers plenty of time to establish a trend line. A week is defined as Friday-Thursday on the SCDHEC website, thus week one is March 1-March 7 all the way through week seven, which is April 12-18. In Figure 3, there are three different data sources: @scdhec daily Twitter report (blue line), weekly cases shown in Table 1 at www.scdhec.gov (orange line), and cases reported in the Morbidity and Mortality Weekly Report (gray line). While there are some minor inconsistencies across these sources, the trends track very well together. Weeks six and seven are still estimated on the website for two of the data sources and not presented here.
So, what’s the verdict? We would say be encouraged, but more time is needed. Even the most optimistic view shows a seven-day period of downward trajectory. The White House Guidelines would suggest we have seven more days to go before any decisions can be made.
2: Social (Physical) Distancing and Protective Measures
We’ll work from the assumption that you know the basics: wash your hands, don’t touch your face, avoid social gatherings of more than 10 people, stay home if you feel sick, keep six feet between you and others, etc. The White House Guidelines have expanded to include explicit suggestions for employers. These include things like temperature checks and monitoring of workforces, development of procedures for contact tracing, encouraging telework, and limiting business travel. There are also statewide guidelines now published related to protecting the health and safety of workers in critical industries, the supply of Personal Protective Equipment (PPE), and protecting those in high-risk facilities or situations.
By now, there should be no confusion about the importance of these measures. At the same time, there is not a predictive measure of a state’s ability to follow the rules. It’s up to the people—the citizens, the employers. Ultimately, most of this is up to us, our friends, and our neighbors. There are no data trends to show here; we have only the “eye test” over the last month balanced with a few tenuous days on South Carolina’s beaches in March, as one example.
So, what’s the verdict? While there is reason to be concerned about the ability to meet some of the statewide requirements, that’s a post for another day. We have faith in the people of South Carolina to follow the individual-level guidelines mostly because anything else is just too stressful to think about. Let’s give this box a tentative check mark and move on.
3: Testing, Testing, Testing
If you follow either of us on social media, you know that we have been beating this drum for a long time. It’s not our drum, per se, but testing is a very clear, evidence-based criteria for a safe path forward. The White House Guidelines say states should have “… ability to quickly set up safe and efficient screening and testing sites for symptomatic individuals and trace contacts of COVID+ results.”
An article in the Post and Courier yesterday called South Carolina’s public health system “one of the most depleted in the nation.” This isn’t SCDHEC’s fault, rather the result of budget cuts and a depleted public health workforce. It’s not the fault of those currently in the workforce either. In fact, we have countless colleagues on the frontlines of our state’s public health infrastructure—at SCDHEC and otherwise—and they are doing a remarkable job with the resources they have available. They deserve our thanks and praise, but they have been dealt a bad hand. The numbers back up this harsh reality.
As of April 18, a total of 38,833 tests have been performed in the state or a little less than 900 tests per day, since March 6. The aforementioned Harvard study estimates South Carolina is currently testing at a rate of 28 tests per 100,000 people per day. What is needed according to this study? A minimum of about 152 tests per 100,000 people each day. A 600% increase of the current condition. Where will those tests come from? Are there enough resources and technology to ever reach that level? We haven’t even gotten to the contact tracing and surveillance parts of the equation yet; this is just the testing infrastructure required.
So, what’s the verdict? An emphatic no, at least not yet.
What is the answer?
One thing is clear, there are no easy answers. In South Carolina and across the country, unemployment claims are at record highs. Individuals and small businesses are suffering. As small business owners ourselves, we want nothing more than to see the day that these trends can begin to reverse themselves. Yet, the current numbers and data are not working in our favor.
Ultimately—this week or otherwise—our Governor and his advisors will have to make some very difficult decisions. Following direction from the Governor, businesses, schools, families, and individuals will all have to make decisions of their own about when and how to “get back to normal” (whatever that will mean going forward). Those decisions will be more palatable and safer when we can answer YES to the three questions we have explored here. As a quick summary, our current scorecard shows one vote for encouraged with more time needed, one tentative yes, and one emphatic no.
You decide.
-----------------------------------------------------------
Forrest Alton, MSPH, is the president and co-founder of 1000 Feathers www.1000feathers.com.
Dr. Heather Brandt is the co-founder of 1000 Feathers and associate dean in the Graduate School and professor in the Arnold School of Public Health at the University of South Carolina.
