President Donald Trump took a lot of flack recently for comments he made about the coronavirus outbreak, including an assertion that because the illness caused by the virus is mild in most cases, many "go to work, but get better."
The president didn't come right out and say everyone should head on in, regardless of whether they have a cough, fever or other COVID-19 symptoms. But his comments acknowledged that working while sick, in America at least, is commonplace.
In doing so, he missed an opportunity to decry this particular practice, public health experts say.
The president's remarks were technically correct; symptoms are indeed mild for most, and many don't even get sick enough to bother seeking medical attention.
But that's only part of the story.
Paul Offit, an internationally respected and often-outspoken virologist and immunologist at Children's Hospital of Philadelphia who has authored several books that push back against the anti-vaccination movement, said that communicating the bigger picture is particularly important in a situation where a "novel" virus is involved.
Because most immune systems have not yet encountered this particular microbe, most people that an infected person encounters are fertile ground for transmission. That's not the case for something like a regularly circulating strain of the flu where some who are exposed won't transmit because they're already immune.
"COVID-19 is likely to spread through the United States because there is no population immunity in place as there is with other viruses that we've seen before," Offit said.
It's probably too late to stop this particular virus from making its way through communities from sea to shining sea, experts say. There are just too many complex interactions between the hundreds of millions of people who live here to quarantine everyone with possible exposure.
In that kind of environment, then, it's on individuals and organizations to do what they can to limit the spread. The key is to limit the number of cases to a level that can be served by available medical resources.
The truly heartbreaking aspect of China's outbreak was that it snowballed so fast from a few cases to thousands that the demand for relatively commonplace medical interventions quickly overcame available treatment capacity.
Absent an effective vaccine, one of the most important ways that people can put the brakes on transmission is to stay away from others when symptoms appear.
This is nothing new. It's the same old advice that public health departments give every year when flu season approaches. The problem has nothing to do with medicine and everything to do with culture, says Dr. Ashish Jha, incoming dean of the Brown University School of Public Health and outgoing director of the Harvard Global Health Institute.
The physician is the first to admit that he has been part of the problem. Everyone has.
"As a practicing physician, I'm embarrassed to say that I have gone to work sick, because that is the cultural expectation," Jha said. "Every other physician I know has also gone into work sick. I've seen nurses come to work sick, not because any of us want to infect other people, but because it's the cultural norm that you've got to be tough, and you've got to carry your responsibility."
But, thinking like an epidemiologist, it's the exact wrong approach.
Staying home, if you're trying to stop something from spreading, should be lauded. And it's not like anyone is really saying that workers and students should come in if they're unwell. Everyone says to stay home but there is a cultural understanding that the social expectations are often different than the official message.
What's needed, public health officials say, is cultural change.
"What we need to say to people is, 'when you are sick, you are not being a burden on your company or your coworkers by not coming to work,'" Jha said. "You're actually doing everyone a favor by taking care of yourself, because that means you're not infecting your co-workers and you're not infecting customers."
But that's clearly not enough. Actions, not talk, are what matters. And here, Jha says, it's the leaders who have the most room to improve. Changing culture is a lift so heavy that it's generally only accomplished if it starts at the very top.
"People in senior leadership positions, whether they're in companies or the government, need to not just say 'please don't come in if you're sick'; they need to take that action themselves when they themselves get sick and really broadcast that action to the people they oversee," Jha said. "They need to take it as an opportunity to explain why they didn't come in, and why that's an important and expected action for the whole organization."
And it's important, Offit adds, that this isn't just a coronavirus thing. Far more people die of the flu every year than are likely to be affected by the current COVID-19 scare and the same kinds of messages should be sent from the top for common illnesses such as influenza.
"If anything good comes out of this whole situation around COVID-19, it would be great if it was changing the culture in this regard," Offit said.
But it's hard, both experts say, to make cultural change if those behind the bully pulpits, those with social media audiences in the millions, aren't tuned in.
"It is extremely unhelpful to have the president say you should just power through it and work through it because that is, in fact, the opposite of the advice we should be hearing right now from our political leaders," Jha said.
While there may not be much agreement in the message emanating from Washington, D.C., it was the opposite last week in San Diego County. Supervisors Nathan Fletcher and Greg Cox were united in their call for local companies to make it easier for employees, especially those with service jobs that cannot be handled through telecommuting, to stay home when they or their family members are sick.
Fletcher was clearly the most comfortable making a specific ask of business.
"We need you to help facilitate employees who feel sick having the opportunity and availability to stay home," Fletcher said. "We don't want individuals to be faced with the situation where they feel like they have flu-like symptoms but in order to pay the rent, they feel like they have to go to work."
It's a little unclear, at the moment, whether the $8 billion coronavirus aid package approved by Congress and the president could be used to help companies defray staffing costs arising from keeping employees home. Though such expenditures are not specifically itemized in the 28-page law, the legislation does grant a select group of federal agencies broad authority to "support the prevention of, preparation for, or response to coronavirus domestically and internationally," subject to congressional oversight.
The package also includes specific mention of funding emergency telehealth operations, which can help control the spread of disease by allowing sick patients to chat with doctors without having to be physically present in their doctor's office.
Dr. Wilma Wooten, the county's public health officer, made it clear during a press conference Thursday that her organization is trying to take its own advice.
"My colleague, Dr. Eric McDonald, who was supposed to be here today, woke up with a cold and sore throat, so he is not here with us," Wooten said. "He is practicing the messages that we give out to the general public."
ABOUT THE WRITER
Paul Sisson covers health care for The San Diego Union-Tribune. He is a member of the Association of Health Care Journalists.
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