How straight talk helped one state control Covid-19

The state of Maine has the nation’s oldest population, with an average age of 45.1 versus 38.5 for the US overall. It is also among the country’s poorest. Fewer than one third of residents hold a bachelor’s degree or higher. Yet despite these risk factors, Maine has a remarkably low prevalence of Covid-19: at last count, there have been 5,780 cases (about 430 per 100,000 people), 463 hospitalizations and a mere 143 deaths. The state’s Covid-19 test positivity rate—averaging roughly 0.5 per cent—is the lowest in the nation. In comparison, equally rural and far flung North Dakota, with roughly 60 per cent of the population of Maine and an average age of 35.5, has suffered 28,244 cases (about 3,700 per 100,000 people), 357 deaths and a test positivity rate of roughly 8.1 per cent.

The face of Maine’s successful policy is Nirav Shah, director of the Maine Center for Disease Control and Prevention. Shah’s rock star status is reflected in his impressive Twitter following, a Facebook fan club and even an electronic road sign on the state’s Route 196 that blinks “In Shah We Trust.” The fact that a self-described “brown guy with a funny name from another state who has been here for 400 days could be viewed as a voice for science,” Shah has tweeted, “speaks more about the character of Maine people than anything else could.” Clearly, that “voice for science” has had a powerful influence. Cell-phone-tracking data indicate that Maine residents have sharply curtailed travel since March. And surveys suggest a general adherence to public health advice on mask wearing and social distancing, even in outdoor spaces such as hiking trails.

Trained in law and economics as well as medicine, Shah takes a broad view of public health that relies on equal parts science, persuasion and empathy. His twice-weekly public radio briefings follow three principles: never shy away from the truth, answer questions directly, and acknowledge the statistics and numbers without overlooking the human element. Our national approach, he says, does not adhere to those principles.

This month 23 states—from Alaska to New Mexico—have reported record numbers of Covid-19 cases. As the days grew shorter, and the nation began to face what many fear will be a viral second wave, Shah spoke with Scientific American about how lessons learned in Maine might be applied to curb the disease across the country and the world.

[An edited transcript of the interview follows.]

What sets Maine apart in terms of limiting transmission?

First, the people in this state believe in science. We know from cell-phone-tracking data that when we asked them to stay home, they did. When we asked them to wear masks, they did. Not everyone, of course, but most. They took heed of public health folks, took our advice to heart. When I chat with my colleagues in other states—Ohio, Michigan—I hear things are entirely different.

Maine seemed to respond to initial reports of the virus far sooner than many other states, including Massachusetts and New York, both of which suffered from frightening outbreaks last spring. Can you explain what tipped you off?

I worked in Cambodia at the start of the SARS epidemic and also through part of the avian flu outbreak. I was part of a large team there, and I learned a lot about the politics of epidemics and the resistance public health experts face. I still have close contacts in Asia, and late last year I heard about a cluster of fevers in December. And the chorus of warning voices grew between Christmas and New Year’s. As soon as we all returned from the New Year’s break on January 2 or 3, my office started to prepare. By February 8, we had distributed PPE [personal protective equipment] to nursing homes, hospitals and first responders. We had our contract tracing plan all mapped out. This was weeks ahead of our first documented case of Covid-19 on March 12.

How important are testing and contact tracing to your response?

They’re essential. Though we’ve had relatively few cases, we have 100 people tracing, and we have plans to hire more. Since May, we’ve partnered with a Maine-based laboratory, IDEXX, that has a very deep bench in reagents. So unlike some states, we’ve had no problems getting reagents for tests. Everyone in the state 12 months or older can get tested at no cost, no questions asked.

Do you think part of Maine’s success comes from its being relatively rural and remote?

Not really. Other rural states such as Idaho, the Dakotas, West Virginia have much higher rates. That suggests that geography doesn’t have much explanatory power.

What metrics do you rely on to measure success?

Our goal is not to eradicate the disease but to suppress the virus to put us in a favorable position for vaccination. Our test positivity rate is consistently under 1 per cent, and for weeks it [remained] under 0.6 per cent. That’s the lowest in the US, and we think that puts us in a good position.

What went wrong with the federal government’s response to the virus?

It’s unclear…. We do know that on February 25, when [Nancy] Messonnier, [head of the Centers for Disease Control and Prevention’s National Center for Immunization and Respiratory Diseases], warned Americans to prepare for a pandemic, she was threatened [with firing by President Donald Trump in a call to the Secretary of Health and Human Services, according to reporting by the Wall Street Journal] and the CDC started to take a back seat.

What would be your first step in changing the federal response?

Stop candy coating. The communication approach has been filtered through what folks in Washington, D.C., want the intended impact to be: it’s outcome driven, and that doesn’t work. They have to stop shaping the message to conform with what they think people want to believe.

Can you a give concrete example of this distorted messaging?

The rollout of [the antiviral] remdesivir, as though it were “mission accomplished.” We actually knew very little at that time about whether the drug worked in the treatment of Covid-19. This happened with other therapies as well.

You give regular press briefings on public radio, as well as daily interviews on Maine AM radio. What do you hope to accomplish with these frequent interactions with the press and public?

All too often, government is on the defensive, and our first inclination is to say, ‘Here’s what [the government has] done; here’s what we need to do.’ But in a high-anxiety, low-trust situation like this, you have to empower people to act. Every five or six weeks, I take stock of where we are and come up with a couple of key asks of the people in Maine. For example, this week, I asked them to commit to get a flu shot. It’s a concrete call to action, something everyone can do for themselves and their family. And it builds confidence and trust.

The president has claimed that he did not inform the public early about Covid-19’s seriousness in order to avoid causing panic. Could too much truth telling engender such a reaction?

What President [Donald] Trump says often has a grain of truth: of course panic is never good. My goal is not to cripple people with fear, but nor is it to give them a false sense of security. I try to encourage them to go forth into activities with knowledge of the risks and with proper precautions. If they feel they must go attend a crowded Sunday morning revival meeting where the risk level is very high, I recommend they wear a mask. If they choose to go out for a hike, I encourage them to do so, knowing that the risk is very low.

Do you think a full economic shutdown is necessary to control Covid-19’s spread?

Last March and April we knew very little about this disease, and that led to a shelter-in-place mentality. We needed to be there then, but we’re not there now. We know that most folks with this disease will [eventually] fare well. We still need precautions, of course, but we also need to offer context. Nuance doesn’t work well in public health, but when I see people driving alone in their cars wearing a mask, well, there’s no need for it.

So what do you propose we do to turn the epidemic around on a national level?

We need a much stronger federal voice advising us. First, I’d return the daily CDC press briefing. I’d start every briefing with the hard facts and follow it with a call to action—lay out specifics on what citizens can to do help themselves and their families. I’d bring back the many experts who resigned from the CDC—we need them—and also strengthen the agency’s presence in Washington, D.C., which is where it all happens. And I’d encourage the CDC and other government agencies to present a grand unified theory of Covid-19—that is, to clearly lay out goals, metrics and strategies for the American people. Because in public health, our first and most important job is to get the people behind us.