A team of SHP faculty and researchers, together with Stanford Medicine graduate and medical students and in collaboration with colleagues at CIDE in Mexico, have launched a modeling framework to investigate the epidemiology of COVID-19 and to support pro-active resource planning and policy evaluations for diverse populations and geographies — including California, Mexico and India.

The Stanford-CIDE Coronavirus Simulation Model — or SC-COSMO — incorporates realistic demography and patterns of contacts sufficient for transmission of the virus that has infected more than 2 million people worldwide and claimed more than 125,600 lives, according to the widely used Johns Hopkins COVID-19 map which is updated several times a day.

The SC-COSMO model also incorporates non-pharmaceutical interventions, such as social distancing, timing and effects on reductions in contacts which may differ by demography.

Jeremy Goldhaber-Fiebert, an associate professor of medicine at Stanford Health Policy, is the principal investigator of the project, along with Fernando Alarid-Escudero, an assistant professor at the Center for Research and Teaching in Economics (CIDE) in Mexico and Jason Andrews, an assistant professor of medicine (infectious diseases) at Stanford Medicine. Other SHP faculty among the 20 investigators and staff members who are working on the project are Joshua Salomon and David Studdert, both professors of medicine.

The SC-COSMO team is a multi-disciplinary, multi-institutional team including expertise and experience in infectious disease, epidemiology, mathematical modeling and simulation, statistics, decision science, health policy, health law and health economics.

“As COVID-19 transmission occurs throughout the world’s diverse populations, it is critical to efficiently model and forecast its future spread between and within these populations and to appropriately reflect uncertainty in modeled outcomes,” Goldhaber-Fiebert said. “Doing so supports timely resource planning and decision making between potentially appropriate and effective interventions that balance the trade-offs they embody.”

The team is currently working on three projects:

1. The researchers are providing California with county-level COVID-19 estimates for such things as the number of infections, detected cases and projections of future needs for hospital and ICU beds, personal protective equipment (PPE) and ventilators.
2. The project is working on potential strategies to mitigate the COVID-19 pandemic in Mexico by focusing on three specific objectives: collecting, synthesizing and openly sharing the most relevant and useful data; accelerating the development of the SC-COSMO model and its adaptation to the Mexican situation; and identifying a set of mitigation strategies, comparing the health and economic consequences in the population in the medium and long term.
3. They are developing forecast models of the COVID-19 epidemic in India with the Wadhwani Institute of Artificial Intelligence and its Indian government partners, providing a rapid response to urgent needs for planning and resource allocation.

Stringent social-distancing rules and other restrictions aimed at addressing the Covid-19 pandemic have brought a large part of the world to a screeching halt and dramatically changed current daily life for millions of people around the globe. In the U.S. alone, the economic toll was underscored this week when the U.S. Labor Department reported that another 6.6 million people filed for unemployment last week, bringing the total number of job losses to more than 16 million over the last month. 

How long can a nation of 327 million people endure with work and schools closed, lost jobs, and people still dying from a pandemic with no proven treatment? And, as the number of new infections starts to level off, will Americans be willing to continue to adhere to such strict measures?  

In a perspective published in the April 9, 2020, issue of the New England Journal of Medicine, David Studdert, professor in both Stanford’s law and medical schools, and Mark Hall, professor of law at Wake Forest Law School, analyze the tension between disease control priorities and basic social and economic freedoms. 

“Resistance to drastic disease-control measures is already evident. Rising infection rates and mortality, coupled with scientific uncertainty about Covid-19, should keep resentment at bay — for a while. But the status quo isn’t sustainable for months on end; public unrest will eventually become too great,” writes Studdert and Hall.

In the perspective, titled “Disease Control, Civil Liberties, and Mass Testing — Calibrating Restrictions during the Covid-19 Pandemic,” the authors advocate for a graduated path back to normal that is guided by a population-wide program of disease testing and surveillance.

Read the Perspective

Half of the medical students in the United States are women, as are two-thirds of the health-care workers taking care of patients in hospitals, clinics and residential communities.

And the majority of the nurses on the frontlines of the COVID-19 pandemic? Women.

Yet gender bias and workplace harassment continue to plague women who have dedicated their careers to taking care of others.

A classic example given by Michelle Mello in a Perspective published in this week’s New England Journal of Medicine goes like this: A female attending physician and a male resident respond to a call to the emergency department. The ED staff direct questions about medical decisions to the man, addressing the logistics to the woman.

“The resident looks awkwardly at the attending but says nothing,” Mello writes. “Gesturing at the attending, the patient says he hopes `the hot new nurse is going to be mine.’ Everyone ignores the comment.”

Sexual harassment and gender bias remain highly prevalent in medicine, ranging from the banal comments by the patient in the scenario above to aggressive misconduct that can damage female health professionals’ well-being, careers and quality of care.

Healthcare organizations have formal processes in place to respond to complaints of workplace discrimination, but these processes “are insufficient to transform cultures,” writes Mello, a professor of medicine with Stanford Health Policy and a professor of law with Stanford Law, and her co-author Reshma Jagsi, director of the Center for Bioethics and Social Sciences at the University of Michigan.

Health-care professionals of both genders must speak up.

“We believe health professionals have a moral duty to practice `upstanding’ — intervening as bystanders — in response to sexual harassment and general bias and that this obligation should be described in codes of medical professional ethics and supported within institutional training,” the authors write.

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While many medical professional societies now mention sexual harassment in their ethical codes, these guidelines fall short in that they do not encourage professionals to respond to the behaviors and intervene when they become aware of discrimination or harassment. The only large specialty society whose guidelines contain “aspirational advice” to stop sexual harassment in its tracks is the American Association of Orthopaedic Surgeons.

The American Medical Association (AMA) Code of Ethics Opinion 9.1.3 requires only that physicians “promote and adhere to strict sexual harassment policies in medical workplaces.” Mello and Jagsi note a striking contrast to the AMA’s approach to physicians who appear to be impaired (for example, due to substance use or mental health problems): Opinion 9.3.2. requires that physicians “intervene in a timely manner” to ensure that impaired colleagues stop practicing and get help.

“Absent stronger exhortation from within the profession, the norm will continue to be that clinicians are lauded when they stand up to harassment or bias but do not feel obligated — and they are not trained and equipped — to do so,” the authors write.

They recommend formal training in bystander intervention and peer-to-peer coaching, using tip sheets describing various courses of action, like this one adapted from Mary Rowe, an adjunct professor of negotiation and management at MIT Sloan.

A policy brief by the Stanford Institute for Economic Policy Research (SIEPR) by several of our faculty members.

By Maria Polyakova, Jason Andrews, Stephen Luby and Jeremy Goldhaber-Fiebert

Even as people follow the rules of social distancing during the coronavirus pandemic, many still ask how they can best keep themselves safe when it comes to grocery shopping or being in situations where others are clustered. Should I wear gloves? And what about masks? Once businesses reopen and people head back to stores and restaurants, will wearing a medical mask still offer a smart level of protection?

The United States, Austria and some other countries outside of Asia — where mask use is already much more common — are now starting to consider recommending or are already requiring that people wear medical masks in public.

But the World Health Organization still recommends against wearing medical masks as long as you’re feeling well. The big reasons, they’ve argued, is that masks are ineffective and may increase risk to those who wear them incorrectly.

That recommendation deserves reconsideration, especially as policymakers think about what steps can be taken to ensure public safety while allowing more economic activity to resume.

What the Evidence Shows

Empirical evidence from existing observational studies and randomized trials supports the effectiveness of medical masks in reducing transmission of respiratory infections in a variety of settings.

Most observational studies, particularly around the SARS outbreak, have found mask wearing protects against infection. The evidence from randomized trials has been more mixed.

Several trials, conducted in community and health care settings, showed that wearing masks — when combined with thorough handwashing — proved to protect against respiratory infections, while other trials found no benefits. In many of these studies, less than 50 percent of participants actually used the protective measures, so that if more people take up these measures in the face of the pandemic, the benefit may be larger than what was found in the trials.

The most comprehensive reviews of the literature on the effectiveness of masks for interruption or reduction of the respiratory virus spread were conducted by Jefferson et al. in a 2011 Cochrane report and MacIntyre and Chughtai’s 2015 overview of the evidence.

Both reviews concluded that existing research supports the notion that having people wear masks makes good sense. Even if it can’t be measured with absolute certainty how much masks alone are responsible for cutting infection rates, there is no evidence to suggest that wearing a mask is dangerous for one’s health.  Both reviews acknowledge that the design, sample size, and analyses of the underlying studies are frequently non-ideal, limiting definitive conclusions on effectiveness. Nevertheless, the balance of evidence suggests a benefit of mask use in community settings, including among those who aren’t feeling sick, especially when masks are deployed early with respect to exposures and used in conjunction with other measures.

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What Policymakers Can Do

As recently pointed out by some scientists following COVID-19, WHO’s recommendation against the use of masks by healthy people in community settings is based on the interpretation of this existing body of research as providing no evidence for the effectiveness of mask use in the community. The Centers for Disease Control and Prevention had followed a similar interpretation in the U.S., though both it and the WHO recommend the use of masks for symptomatic patients and health care professionals as effective means of preventing transmission.

While the quality of evidence supporting the effectiveness of masks in health care settings is certainly better, the firm recommendation against masks in community settings appears incompatible with the available evidence.

The strength of the recommendations against wearing masks appear to stem from two additional concerns: that the public would wear masks incorrectly, undermining their effectiveness; and that wide-spread community use would exacerbate mask shortages for health care professionals.

The World Health Organization has indicated that wearing masks incorrectly can increase one’s risk of infection. But there is not sufficient evidence to support the notion that people could not wear masks effectively. Many masks are packaged with detailed instructions for how to use them. And online videos could easily be posted to teach people how to wear a mask correctly. The theoretical risk of increasing acquisition of infection, while frequently cited by authorities, does not seem to be supported by a finding of increased risk in any of the available studies.

Appeals to the public not to stockpile masks so as to keep them available for health care professionals have generally not been effective, with widely reported stock-outs and shortages despite such appeals. We speculate that such appeals failed because the general public did not find the argument that masks are ineffective in community settings to be credible.

Moreover, it is possible that initial (and ongoing at the time of this writing) WHO and CDC guidelines against the use of masks in the community by individuals without symptoms may have unintentionally decreased the required sense of urgency and commitment of private and public resources for addressing underlying mask shortages for the general population. The result is that acute shortages of masks undercut even existing CDC recommendations; many individuals who are ill or visiting a health care facility with suspected COVID-19 symptoms cannot obtain masks.

Revising recommendations for expanding the use of masks in public areas in the U.S. is justified by the evidence. And guidelines to wear masks as part of other public efforts — including social distancing — to control the spread of COVID-19 could help steer the production energy and resources of both private and public players to ensuring there are enough masks for everyone.

Supporting the Economy

We further speculate that deployment of masks in public areas may eventually help the economy with transitioning into the post-COVID world.

First, masks could prove to be a cost-effective way of trying to reduce re-emergence of the virus in the medium run, as epidemiologic models suggest that virus re-emergence may necessitate re-introduction of social distancing measures with some regularity over the course of next 12 to 18 months (Flaxman et al. 2020). But wearing masks could give some hope of removing the need to put the economy into the switch on, switch off mode — which would require many businesses to close, open, and close again on short notice

Second, once official restrictions on many forms of economic activity are lifted, it is very likely that consumers will be hesitant in returning to their pre-pandemic levels of consumption of goods and services outside of their homes. Consumers’ behavioral sentiments are crucial for charting course of economic activity, while prolonged uncertainty may be harmful for firms (Bloom 2009).

Having a mask and knowing how to use it may serve as an extra crutch to help with inevitable consumer anxiety.

Policy Brief References

Jay Bhattacharya is a professor of medicine at Stanford Medicine and a core faculty member at Stanford Health Policy. His March 24, 2020, commentary in the Wall Street Journal questions the premise that “coronavirus would kill millions without shelter-in-place orders and quarantines.” In the article he suggests that “there’s little evidence to confirm that premise—and projections of the death toll could plausibly be orders of magnitude too high.”

In this edition of Uncommon Knowledge with Peter Robinson, the Murdoch Distinguished Policy Fellow at the Hoover Institution, Robinson asks  Bhattacharya to defend that statement and describe to us how he arrived at this conclusion. We get into the details of his research, which used data collected from hotspots around the world and his background as a doctor, a medical researcher, and an economist.

Taiwan is only 81 miles off the coast of mainland China and was expected to be hard hit by the coronavirus, due to its proximity and the number of flights between the island nation and its massive neighbor to the west.

Yet it has so far managed to prevent the coronavirus from heavily impacting its 23 million citizens, despite hundreds of thousands of them working and residing in China.

According to the Johns Hopkins Coronavirus COVID-19 Global Cases map, as of Tuesday there were only 42 cases and one death in Taiwan, far behind China, with more than 80,000 cases and more than 2,900 deaths. The country also lags far behind its other Asian neighbors and ranks 17^th in the world for the number of global cases. As of this writing, South Korea was second, with 5,186 cases; followed by Iran with 2,336 and Italy with 2,036 people infected with the virus.

The United States currently stands at 107 known cases and six deaths.

The viral outbreak in China occurred just before the Lunar New Year, during which time millions of Chinese and Taiwanese were expected to travel for the holidays.

So what steps did Taiwan take to protect its people? And could those steps be replicated here at home?

Stanford Health Policy’s Jason Wang, MD, PhD, an associate professor of pediatrics at Stanford Medicine who also has a PhD in policy analysis, credits his native Taiwan with using new technology and a robust pandemic prevention plan put into place at the 2003 SARS outbreak.

“The Taiwan government established the National Health Command Center (NHCC) after SARS and it’s become part of a disaster management center that focuses on large-outbreak responses and acts as the operational command point for direct communications,” said Wang, a pediatrician and the director of the Center for Policy, Outcomes, and Prevention at Stanford. The NHCC also established the Central Epidemic Command Center, which was activated in early January.

“And Taiwan rapidly produced and implemented a list of at least 124 action items in the past five weeks to protect public health,” Wang said. “The policies and actions go beyond border control because they recognized that that wasn’t enough.”

Wang outlines the measures Taiwan took in the last six weeks in an article published Tuesday in the Journal of the American Medical Association.

“Given the continual spread of COVID-19 around the world, understanding the action items that were implemented quickly in Taiwan, and the effectiveness of these actions in preventing a large-scale epidemic, may be instructive for other countries,” Wang and his co-authors wrote.

Within the last five weeks, Wang said, the Taiwan epidemic command center rapidly implemented those 124 action items, including border control from the air and sea, case identification using new data and technology, quarantine of suspicious cases, educating the public while fighting misinformation, negotiating with other countries — and formulating policies for schools and businesses to follow.

Big Data Analytics

The authors note that Taiwan integrated its national health insurance database with its immigration and customs database to begin the creation of big data for analytics. That allowed them case identification by generating real-time alerts during a clinical visit based on travel history and clinical symptoms.

Taipei also used Quick Response (QR) code scanning and online reporting of travel history and health symptoms to classify travelers’ infectious risks based on flight origin and travel history in the last 14 days. People who had not traveled to high-risk areas were sent a health declaration border pass via SMS for faster immigration clearance; those who had traveled to high-risk areas were quarantined at home and tracked through their mobile phones to ensure that they stayed home during the incubation period.

The country also instituted a toll-free hotline for citizens to report suspicious symptoms in themselves or others. As the disease progressed, the government called on major cities to establish their own hotlines so that the main hotline would not become jammed.

Some might say that because Taiwan is such a small country — about 19 times smaller than Texas — it is easier to mobilize during emergencies. Yet Taiwan is particularly challenged by its proximity to China and the fact that 850,000 of its citizens reside on the mainland; another 400,000 work there. Taiwan had 2.71 million visitors from China last year.

So when the WHO was notified on Dec. 31, 2019, of a pneumonia of unknown cause in Wuhan, China, Taiwanese officials began to board planes and assess passengers on direct flights from Wuhan for fever and pneumonia symptoms before passengers could deplane.

As early as Jan. 5, notification was expanded to include any individual who had traveled to Wuhan in the past 14 days and had a fever or symptoms of upper respiratory tract infection at the point of entry. Suspected cases were screened for 26 viruses, including SARS and MERS. Passengers displaying symptoms were quarantined at home and assessed whether medical attention at a hospital was necessary.

What the U.S. Could Learn

One of Wang’s co-authors, Robert H. Brook, M.D., ScD., of the David Geffen School of Medicine at the University of California, Los Angeles, said Washington could learn a great deal from Taiwan’s so-far successful management of the virus.

“In Taiwan, diverse political parties were willing to work together to produce an immediate response to the danger,” said Brook, also of the nonprofit RAND Corporation. “Transparency was critical and frequent communication to the public from a trusted official was paramount to reducing public panic.”

The other co-author of their study is Chun Y. Ng, MBA, MPH, of The New School for Leadership in Health Care, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan.

Brook said Taiwan got out ahead of the epidemic by setting up a physical command center to facilitate rapid communications. The command center set the price of masks and used government funds and military personnel to increase mask production. By Jan. 20, the Taiwan CDC announced that it had a stockpile of 44 million surgical masks, 1.9 million N95 masks and 1,100 negative pressure isolation rooms.

“In a country as complex as the United States,” Brook said, “there needs to be a sharing of intelligence on a real-time basis among states and the federal government so that action is not delayed by going through formal channels.”

Please contact Beth Duff-Brown for media requests.