Going Viral: A Conversation On COVID-19 With Dr. Aaron Carroll

As someone who researches the healthcare industry, you must have been tracking the novel coronavirus from the beginning. When did you first start worrying about it?
Well, the first thing to say is that I’m also just a citizen. I don’t have access to special reports or data. I remember hearing about this at the beginning of January. At that point, the news coverage was mostly focused on China, and there was still hope that China might contain it. I write a column for The New York Times, and my pieces from that period tried to convey: Hey, there’s this virus, here’s the data about it, here’s what we know about its spread. I got more worried in February. In the third week of that month, I was on a trip to Switzerland and the Netherlands with some students. We noticed that the European media was covering the virus much differently than American media. We realized that the virus was not being contained. Italy was particularly concerning, with the virus spreading quickly and overwhelming its healthcare infrastructure. That was when I started getting concerned that our public efforts and our government were not grasping the reality of this situation.

So what did you do next?
As soon as we got back from the trip, I said to my wife, “The next time you go to the supermarket, you might grab some extra meat and throw it in the freezer. We might end up spending some time at home.” “You’re panicking,” she said. She was teasing me because I’m not one to panic. But that did set off my family—they knew that if I was worried, it was time for everyone to worry.

This sounds like the domestic version of a Tweet you sent in early March: “I’m not the guy who tells you to panic—I’m the guy who usually tells you not to. So when I say I’m worried, I hope you’ll listen.”
Right. One of the main themes in my work is that people tend to overestimate risk. They don’t put risk in a proper context—they don’t think about and understand all of the risks people face every day. With the coronavirus, though, I don’t think most Americans were fully aware of how dangerous it could be. And that includes me. We did not take this as seriously as other countries did, partially because they’d been through other pandemics like SARS. So I started writing columns that explained what social distancing was and why we needed to do it—to flatten the curve and keep too many people from getting sick too fast.

Social distancing is where most of Indiana is at right now. What does it look like for you?
I recognize I live in a world of extreme privilege. Food is easily delivered in Carmel, Indiana. We live in a suburb, and there is a lot of space. I get up every morning and take an hour-long walk, and I see almost nobody other than a neighbor in his yard or across the street. We’ve all stayed in the house pretty much since this began, except for the occasional car ride to pick up food. We’re doing almost all delivery from local restaurants and grocery stores. We have food dropped on the porch and leave a tip out there. There’s a small, minimal chance the virus could sit on a package, so if the items are nonperishable, we let them sit outside for a while. And when we unpack anything from outside the house, we always wash our hands. One family member will bring the food or packages in and unpack them and then wash their hands. There’s still a huge amount of hand-washing, even inside the home.

You’re doing all of this with three teenagers at home, as well.
I have a senior, a sophomore, and an eighth-grader. They are somewhat on autopilot, and we have loosened the restrictions on them quite a bit. I have no evidence on whether this is the best way to parent right now, but as long as they are getting their schoolwork done and getting some physical activity, we have been letting them run their own lives. They are sleeping pretty late! And they are socializing online. We might have had some screen-time restrictions before this, but now that’s their main way to be social. If they are doing their schoolwork and continuing to be good kids, we’re trying to give them leeway.

In his home studio, Dr. Aaron Carroll records his popular YouTube series Healthcare
Triage.Image courtesy Healthcare Triage

That sounds like the life of a lot of Hoosiers, except that you’ve also had to construct a TV studio inside your home office.
I’m also privileged in that I get to work from home. A lot of it is still my university work—meetings with faculty over Zoom, editing research papers, working on an NIH grant. But I’ve also been doing a lot of writing and some media, talking about what we need to be doing going forward. I have a YouTube show, Healthcare Triage, and when we realized the lockdown was coming, the producer brought me two studio lights and a special camera so I could tape from my office. I’ve been using it for cable TV hits, too. I used to drive to a studio downtown, but now we do all those from home. It’s not perfect. Our dog’s crate is in my office, and sometimes you can see it on TV. But the studio lights do help.

You emerged as an important media expert during the Obama administration—and especially during the debates over healthcare reform. How did that happen?
There was a point in my life—probably 2008 or 2009—when I realized that my job as a health services researcher was in large part the job of being a writer. And I had never been trained to write. English was always my least favorite subject in school. But I was writing grant applications, memos, emails, and I knew I had to get better at all of it. So I made it a goal that I was going to write 800 words a day, every day, for two years, until I became a better writer. I needed something to write about, so I started a blog and ultimately merged it with the blog of another professor. It’s called The Incidental Economist. We’ve been consistent voices, and tried not to be partisan flamethrowers. Healthcare reform was really hot at that time, and I would read the literature, interpret the data and evidence, and then weigh in on the current issues. A lot of the discussions we have about health policy devolve into I think this, you think that. But there are a lot of questions that have answers. I was trying to bring data to a fight that was otherwise political.

So how have you been applying that approach to covering the coronavirus?
Obviously, we don’t have randomized, controlled trials for a new virus. As a writer, I have to play more defense—to say what we know, but just as much what we don’t know, what we will have to wait on. I am trying to explain what we know from experience and history and modeling and other relevant research. And then I am trying to ask how can we apply that to make the best choices. In the current situation, sometimes we have only a week or two to make these decisions. The best data for the United States has probably been what’s happening in western Europe, but there isn’t a ton of time separating us from them, and there are always tradeoffs with these choices.

It’s a really tough situation for politicians and regular people alike. How do you think Indiana has been doing?
It’s hard to talk about the United States as a whole. Some parts of the country are doing really well, and some are not. It’s the same way with Indiana. There are pockets of the state that are doing really well, and there are pockets that are not. In general, I think Indiana got out ahead of this earlier than many other states, especially given where we were on our curve. Because of that, I think we will weather this relatively well. We have not looked like New York has looked. A lot of our local businesses have really stepped up in terms of trying to help and to provide testing. People have generally gotten what we’re trying to do here. There have been some protests, but not as much as in other states. Still, there are areas of the state that have not taken social distancing as seriously. Their peaks may still be weeks away, and there aren’t as many healthcare resources—they have smaller hospitals, fewer ICU beds, and so on.

The New York Times has used anonymous cellphone data to track how much people in various counties are moving around, compared to how much they moved before the start of social distancing. Indianapolis and its surrounding counties have really slowed down, but other parts of the state, especially to the south, seem much closer to their normal travel rates.
That’s true. Some people are still conducting business. But it’s important to think about the context. It’s very easy for me to socially distance. My job is still paying me. I can have food delivered, and I can afford to have it delivered. There are lots of places where it is not as easy. In a rural part of the state, the Kroger may not deliver. When people are going on spring break during a pandemic, I’ll happily point a finger. But other cases may be more complicated. Sometimes it’s a failure of all of us to support every person who needs to socially distance.

A lot of the federal response to the coronavirus has been shaped by former Hoosiers: Mike Pence (vice president), Dr. Jerome Adams (surgeon general), Seema Verma (administrator for the Centers for Medicare and Medicaid), and Alex Azar (secretary of health and human services), among others. How has Governor Holcomb done at home?
Again, I’m just a citizen, but as far as I can tell, Holcomb has done pretty well. Indiana has a reputation for being reasonably pragmatic—for not always being as partisan as some other states. And it does feel like the response here has not been terribly rancorous. It feels like most people are trying to do the right thing. Officials are cognizant of the economic impact, but they’re still listening to the public health experts.

The big question right now is what comes next. You’ve written a lot about Singapore’s attempt to contain the coronavirus, and it’s an interesting comparison for Hoosiers to think about, since that city-state is approximately the size of Indianapolis in terms of surface area, even as its population is closer to the state’s as a whole.
Singapore is a big, crowded city, and they’ve been through this before with SARS. They get lots of travelers from China, so the second they realized the coronavirus was a problem, they were on it. They didn’t have massive social distancing. Instead, they were screening travelers. They were quarantining people. They were setting up a massive system of contact tracing. Singapore tested a lot more widely than we did, and when someone had a positive test, officials gave themselves a two-hour window to figure out how that person got the virus and who else they might have given it to. This was investigative work, and the police were involved. Anyone a person with a positive test had been in contact with had to go into isolation, too. Singapore was testing, and they were tracking, and they were on it.

Two hours! Even granting that Holcomb has done a good job, it seems impossible to imagine Indiana mounting a program like that.
And it hasn’t even worked perfectly in Singapore. They have a reasonably large migrant-worker program, with very tight living quarters, and eventually Singapore lost control of their community spread. So they went into shelter in place, like we are doing now—closing schools, closing businesses. It’s a really important point: Singapore was doing what we will need to do, and they were doing it better than we will do it, and they still had to go back down to lockdown.

A regular guest on MSNBC and other outlets, Dr. Carroll has become a prominent advocate for social
distancing.Image courtesy MSNBC

Barack Obama tweeted out one of your Singapore columns, earning it more than 45,000 retweets and more than 200,000 likes. “In order to shift off current policies,” he wrote, “the key will be a robust system of testing and monitoring—something we have yet to put in place nationwide.” How do we get there?
We need to get down to a number of cases that are manageable in some kind of tracing approach—and remember, we don’t even have the infrastructure for this tracing as of now. We do have some advantages. Indiana is a lot more spread out than Singapore. If we really suppress this and eliminate most community spread, there will be parts of the state that, if people really practice social distancing, can fully reopen. Compact cities with public transit and high-rise buildings are going to have a real struggle. But in Indiana, even when I go back to work in an office at IU, I can stay away from most people. If we’re careful and thorough, we can be OK as long as we build up the infrastructure to monitor this.

Can Indiana count on any help in building that infrastructure?
The tracing has to be done locally. You can’t run it out of Washington, D.C., because you have to know where people live. You have to have people on the ground. But this will cost a small fortune, and the federal government is the only one with the wallet big enough to cover it. There are privacy issues, security issues, legal issues, ethical issues, cellphone-tracking issues. Are we going to set up hotels for isolation? How are we going to ramp up testing? There are already plenty of smart people who know what we need to do. They are already talking about all of it. But I can’t imagine how this will happen without federal investment, and honestly, the government is moving really, really slowly.

What seems to be emerging more quickly is pressure to completely reopen the economy. Some of us are back in the office, but many businesses remain shuttered.
Economists will answer economy questions better than I can. But I’m worried about it. I also think it’s all very complicated. It’s not just declaring, “The economy is open.” We have to make people feel safe. If people are still in their homes, scared to go out, the economy is not open. Until we have herd immunity or better treatments or a vaccine, our best option is that tracing infrastructure. I don’t think critics appreciate how much work we will need to do to make people feel that America has a handle on this.

It all seems to come back to that infrastructure—and it seems that we aren’t making enough progress there.
We still have time to act. Remember that the peak means the worst day. We have a long time to go to get to a good day. But I don’t think right now that we are using this time as wisely as we should be. We should be massively ramping up, training people to do tests, figuring out where in Indiana there might be community spread, figuring out how many Hoosiers have had this. Even having reopened, some spots will have to go in and out of lockdown. We need to be ready to fail multiple times. And then in the fall—what are we going to do about schools? Especially given that, traditionally, other viruses have rebounded in the fall? There are a lot of things we like to do that won’t be possible for a while. Disney World is out. Twenty thousand people watching a basketball game is out. Those are just not good ideas, and they won’t be for a long time.