Coronavirus in Michigan: Six Months Later

Speaker 1: As the coronavirus pandemic unfolded across the United States, the state of Michigan and its people have been under the microscope. Early on, the Great Lakes State gained national attention as a hotspot with some of the highest case counts and numbers of deaths in the country. Then as Michigan's case counts and death total slowed, the state was held up as an example of how to slow the spread.

These days, the national conversation on COVID has mostly moved past our state, but that doesn't mean there isn't still plenty to talk about. It's been six months since Governor Gretchen Whitmer first enacted the stay-at-home order on March 23rd. We wanted to take a step back and examine what we've learned in our state and what we still don't know.

Hello and welcome to Population Healthy, a podcast from the University of Michigan School of Public Health. This episode is part of a series of special editions of our podcast focusing on the ongoing coronavirus pandemic. We spoke to Sharon Kardia, professor of Epidemiology and Associate Dean for Education at the University of Michigan School of Public Health. She’ll help us look back at what's happened across Michigan over the last six months, and we'll learn more about a pair of University projects that helped the state in its response to the pandemic.

Kardia: There are lots of different ways in which Michigan has been affected over the last six months by the pandemic. I think all of us see evidence of it in the way that we work and the way that we are living with our families. There's a lot more attention on exactly where we're going and why we're going there, and whether or not we're bringing masks with us. I think also there's a kind of now seasoned understanding of what brings on risk. It doesn't mean that we don't tempt it. I think the stay home stay safe period hit many people I think very hard because it was the first time in our lives that we had for very good reasons, both the governor and the government saying “stay home, don't go anywhere”. And what that meant was a re-shifting of the way in which we think of our own risk.

When that got lifted at the end of May and we went back, the cases were quite low, and we really felt like we had achieved a lot of progress in terms of beating back the virus in our communities. I think much to our chagrin, then we started to see the South of the United States light up, Florida and Texas and Arizona and many of the other southern states increased precipitously. And then we started to see it here. Outbreaks in Lansing and Saline and places that we just couldn't even have imagined, I think in many ways, a month or so earlier. It took off like a big cannon and hit that area very, very hard, and with that came overwhelm of the healthcare system, and it's those two things together, a precipitous increase in cases and an overwhelm in the healthcare system that leads to the most casualties from a pandemic like this.

We've not had a huge second wave, like many other places around the United States, I think in large part because we got hit very hard the first wave, and we learned that there were indeed things we could do like wear the mask, like keep six feet of distance. And so we developed new norms over the last six months that I think are gonna serve us well for the next six months. There are many of us to continue to be worried that as people travel, especially in the fall, we still might see more percolating across the whole state and outbreaks happen when we let our guards down.

Speaker 1: Six months ago, practices like social distancing and wearing masks were novelties. Six months later, their importance hasn't changed, and public health officials continue to advocate for these practices as our best methods for stopping the spread of COVID-19.

Kardia: When the pandemic started, I think many of us only new flu as a point of reference of something that goes into our communities, spreads like wildfire, makes a lot of people really sick. And for flu, most of the time we focused on washing our hands and coughing into our elbows and doing some basic things that would allow us to avoid getting sick. The pandemic with the coronavirus really started to challenge us to think, well, wait a second, this isn't playing by the regular rules. Epidemiologists had to start tracking was it surfaces, was it closed rooms, what was the real point source of many people's infections?

So the systems that we started to see at first didn't include the things we now rely on. I'll give the example of probably somewhere in April, a clear month after we'd seen this outbreak happening, you started to see barriers go up in grocery stores that would protect the grocery store check-out person as well as you if they were infected. They started wearing masks. So, eliminating the ability for people to unintentionally, through talking, through coughing, sneezing, whatever, to transfer the virus through the respiratory droplets. Those were big system implementations. The other thing is people's interpretation of six feet was pretty wide. Some people were taking twelve feet distance and some people were taking three, so markings on the floors became a very helpful way to figure out and to learn how do I keep a safe distance. And one of the pieces I love about the systems, barriers and markers is that it makes me feel like I'm keeping myself safe from other people, and I'm also assuring them that I'm keeping them safe by following these practices.

The wearing of masks was something that we culturally had never done. I've never seen people in the United States don masks the way they do in some of the Asian countries. And so there was indeed hesitation around that, both culturally and then the bigger one, probably if we really think about the dynamic of March, April, May, is they just weren't around. The N95 masks were very difficult for healthcare providers to get, and what's the use of wearing a mask if it's not gonna be effective. And it took a little bit of time for researchers to really figure out the vast majority of the droplets could be stopped by a cloth mask, and cloth masks of very different types.

One thing I think people don't really understand with the cloth masks is that it's primarily a protection from somebody else. So what do I mean by that? I mean, if I'm wearing a mask, I'm protecting you. Me were wearing a mask, doesn't really protect me from somebody who's not wearing a mask. That's where the N95 masks are essential for health care workers because it protects the healthcare worker. Our cloth masks are really what stop the droplets I might be expressing when I talk from coming into the air and infecting somebody else. I think it's one of the reasons why people get so mad is that if somebody's not wearing a mask, it's like, wait a second, you're not doing your part to protect me in case you are asymptomatic, don't know it and are spreading it. So that's one part of the anger. The other is when people get charged and say something, it feels accusatory. Like oh, you got COVID, wear a mask. And those two things are a little bit like rubbing two hot sticks together, they create a lot of fire, and it would just be better if we could all get into the mindset of, I'm gonna do my part and protect other people from the possibility that I might be carrying the virus and not know it by wearing a mask.

Speaker 1: Since the pandemic broke out a team of experts from the University of Michigan School Public Health has partnered with the state’s Departments of Health and Human Services and Labor and Economic Opportunity. They've provided expertise in modeling and forecasting data, advised on the state’s Safe Start Plan and worked closely with industry leaders to evaluate risk factors for different work settings while developing risk mitigating strategies to re-open those workplaces.

Kardia: So when we started working with the state of Michigan on helping Michigan give back to work, we were with the task force at Michigan Economic Recovery Council that Governor Whitmer had set up. They really needed help better understanding what were the real triggers of increased or decreased risk in populations, like Michigan communities, and they also needed to have a better understanding of how do we mitigate risk for wildly different kinds of occupations. What does a landscaper do versus somebody who’s in commercial construction, versus somebody who's an architect, or somebody who's in K12 education, seems like such different environments. And as we were trying our best to pull from the knowledge that we had in our respective disciplines in the School of Public Health, it more and more became clear to me that we needed to start to think about the situation that we were in like a precision health problem.

And what does that mean? Well, Precision Health has as its core, this main, I'll call it vision, that if we can get the right information at the right time to make the best decisions to improve health, we would have the 21st century best approach, given the kind of world that we live in where information and data is everywhere, but making sense of it and making good decisions by it, and then making sure that they resulted in good outcomes was something that universities are just trying to figure out, well, what are the systems that you need. So what does that mean for Michigan and its response? Well, it means that we started to need to collect data on who had symptoms and who was getting tested, and whether or not the number of cases that we were seeing were actually the tip of the iceberg or much deeper into the population. We had a much better sense of even people who were just mildly sick. And I think many of us have heard that we probably had something like three to ten more cases of COVID then we knew about, and that had to do with the fact that not everybody can get a test early on. It really was only those individuals that were very sick, usually in the hospital or ending up in an emergency room, we're getting tested.

That's an example of where the data was off from what you would really need to better understand how much community spread. So we weren't doing a very precise job. We didn't have the right data at the right time to mount the kind of response that we wanted. But it didn't take us long before we could start to really set our sights. So we developed a few tools and there have been more that every single month seemed to come out, that would enable local and state health officials as well as hospitals and healthcare systems, university researchers, to be able to have access to real-time data on the number of tests that are being done, the number of test results, a number of new cases, the rate at which those cases are changing weekly, so that you can get better forecasting. If you think of weather, the best weather predictions are of the week that you're about to enter. They're not great for predicting weather in two months, but if you take all the temperature, barometric pressure, humidity you can get pretty good accurate measures down to the hour as to whether it’s going to rain in your community or snow. So that's the kind of thing that we have seen in what has been a very natural response to this pandemic, which is to get the information aligned, so that decision makers and the people that are on the ground have everything that they need in order to prioritize their actions and use the limited resources to have the biggest benefit for their communities.

So let me give you two examples of things that the University of Michigan team that I led developed for the state to help them in this precision population health approach. The first was the My Symptoms app, that's a health screening app that we developed using the best epidemiological science, CDC and the Council for State and Territorial Epidemiologists definitions of COVID-like symptoms and COVID-like illness. Working with the Michigan Department of Health and Human Services to really align it so that this would be something that the state of Michigan could roll out, especially to small businesses and people that didn't have the ability to build their own health screening. To do that, we teamed up with the College of Engineering, who we knew were great at everything from building the necessary data infrastructures, but then also they teach app design. So, we worked with Dan Maletta, who's the head of the College of Engineering’s IT and some really talented students, including Kirtana Choragudi who was basically the project lead. They, along with the people in their data infrastructure for the school, Tom Knox and John Parso, really done a masterful job of working with the State of Michigan who gave us a provisional authority to operate, to collect information and feed it back into the state data systems in terms of the aggregate of people that have COVID-like symptoms every day, so they can keep a bean on what's going on. We’re currently working with some students that graduated from their undergraduate degrees in computer science and School of Information, working with School of Public Health faculty, to build a hotspot map for local and state public health officials, so they can see what is happening to the symptoms in a location and be able to figure out, oh, wow, this community really is looking like they have a lot of symptoms, much more so than they did last week or the week before, and to be able to have a little bit of a harbinger of what might be coming down the pike. Symptoms tend to run about five to six days earlier than a positive test result because most people have symptoms and they're not gonna go get a COVID test until they really figure out, oh, wait a second, this might not be something like the common cold. So it gives us a little forewarning.

The other thing that we did to help local and state health officials and the public was to systematically take the data that was coming into the state in terms of the number of tests, number of people that tested positive, number of cases, number of death, and to be able to plot that in a way that made sense to the average person who might need that information in the public as well as to professionals, local and state health officials, in the My Safe Start Map. And the My Safe Start Map we did in collaboration, again, with the Michigan Department of Health and Human Services and their need to communicate risk levels, along with colleagues like Paul Resnick and Michael Hess at the School of Information. They did an incredible job of pulling from their students, staff, faculty, alumni. I think they had like 30 or 40 people at one point meeting and working regularly on what's an incredible dashboard. It's beautiful, it’s streamlined, it has everything that somebody might want to know about the actual cases.

We are starting right now with the Department of Health to try to figure out how do we get some health care capacity added to that. We're constantly working on new features for this dashboard. We're about to put heat maps that let people see the trajectory over time of where COVID has been the highest frequency in what areas of the state. John Zelner who's a School Public Health faculty member in the Department of Epidemiology has been developing those as well as really being able to see the whole timeline and how the actions that the people of Michigan, the Governor of Michigan, the Department of Health, have made and the kind of benefits from the all hands-on-deck approach that Michigan has taken.

So where do we go from here? One thing that all of us need to really take stock on is the kind of mindset that we need to have for a long-term approach to this pandemic. This virus is not gonna go away quickly. We had a small moment, probably in May and early June, where the cases were going down significantly enough that we might have had a chance to really limit the spread of the virus. Unfortunately, we just couldn't hold. And so it gained traction across the United States with millions of people having been infected, and that means it's gonna be percolating through our communities in the United States and in Michigan for quite a while. So one is that we have to think of this not as a sprint, not as a hunker down, we’re going to weather the storm, but more like a long-term battle.

What does that mean? Well, it means, so we have to have a different approach to taking care of ourselves. It means we do have to invest in the things that bring us joy and relief. We don't want to burn out and then just say, forget it, I'm gonna go into denial about it, or I'm gonna think it couldn't happen to me. So figuring out ways, and I think people are incredibly creative. We have to figure out ways to socialize, but stay safe. We're social animals, and so we need the ability to interact in order to feel good about what's happening. Part of it is mental and social, the other is to keep our eyes on what's happening with respect to vaccines. There's likely to be vaccines coming out in the next couple of months and getting a clear view as to what they can do and what they can't do. Basically like flu vaccines, some years they're great and some years not so much. So I think the other is we just have to keep watchful waiting on what's gonna be the next big benefit. This is a time period for all of us to recognize that our world is smaller than we think. This is a virus that has touched every nation and continent, and that really necessity is the mother of invention. It's time for us to invent some new solutions that would allow us to keep ourselves, our families, our community safe, while basically celebrating and recognizing our needs to keep going, whether it's income, or education, or the arts. We need to figure out new ways cause this is gonna be with us for quite a while.

Speaker 1: This has been a special edition of Population Healthy, a podcast from the University of Michigan School of Public Health. During the ongoing coronavirus pandemic, we’ll work to bring you analysis from our community of experts to help you understand what this public health crisis means for you. To stay up-to-date in between special edition episodes, be sure to check out our website publichealth.umich.edu, subscribe to our Population Healthy newsletter at publichealth.umich.edu/news/newsletter and follow us on Twitter, Instagram, and Facebook @umichsph.