Last December, during the state’s second COVID-19 wave, the Michigan Department of Health and Humans Services quietly published a new pandemic response plan. The timing is curious, as it gives the impression that state officials are literally making things up as they go. But more concerning is that this latest plan appears to endorse the historically unprecedented, controversial and legally questionable lockdown orders Gov. Gretchen Whitmer imposed on Michigan society in response to the coronavirus.
The rush to create a new pandemic plan is hard to understand, considering that government officials have found no use for the state’s existing ones. In fact, Gov. Whitmer and public health officials deviated from the state’s official plans from day one of the current pandemic. For instance, those plans do not call for governors to take unilateral control of the state’s entire response. They also do not envision broad and extended business closures or forbidding healthy people from leaving their homes under penalty of law.
The recently published plan differs significantly from existing ones and specifically recommends lockdown-type polices, referred to as “non-pharmaceutical interventions.” It bakes them right into its planning assumptions, which declare, “Non-Pharmaceutical Intervention (NPI) will need to be utilized.” These interventions include limiting the “unnecessary movement in the community/shelter-in-place," “cancelling mass gatherings of more than 10 people” and “implement[ing] teleworking for businesses.” Presumably, it will be up to state officials to, once again, determine what is “unnecessary movement” and what is “essential.”
The document does not explain why a rewrite of state plans was necessary. It does, however, mention updated guidance published in 2017 by the U.S. Centers for Disease Control and Prevention. But that federal guidance does not recommend drastic actions like forcing healthy people to shelter in place or requiring all employees to work remotely. It only goes as far as recommending voluntary quarantining of infected individuals and members of their household. It says that other social distancing mandates, such as temporarily closing schools, cancelling mass gatherings and limiting workplace interactions, should only be considered in the case of very severe pandemics.
And even then, the CDC report repeatedly points out that the evidence on the effectiveness of these actions is limited and that their unintended consequences needs to be considered. For instance, when speaking of social distancing measures aimed at reducing face-to-face contact, it warns, “[D]irect evidence is limited for the effectiveness of these measures.” It also notes that they “are likely to cause unwanted consequences by introducing new norms for social behavior, interrupting routine societal functions, and entailing additional costs.” It’s hard to justify making such drastic actions the default option when so little is yet known about their overall effectiveness and costs.
The state’s latest pandemic plan indicates that lockdowns may be issued even before a pandemic lands on Michigan’s shores. It says, “Social distancing measures such as limiting large gatherings of people, school closing, etc.” should be implemented in the “recognition phase” of a pandemic. The CDC defines that phase as the time when there is the “potential for ongoing human-to-human transmission anywhere in the world.” If the Michigan health department had followed this plan for COVID-19, lockdown policies could have started in January 2020. A lockdown in response to the 2009 H1N1 pandemic would have be justified, too.
The newest plan from the state also calls for “cancelling of elective surgeries” and “postponing of non-emergency surgical procedures.” Gov. Whitmer issued executive orders to this effect early in the pandemic, and these were controversial and probably illegal. The Mackinac Center sued the state on behalf of three medical providers, in response to these orders, and the governor later rescinded them. Restricting access to medical care in this way sacrifices one public health concern for another, and state officials would do better to leave the decisions about how to allocate medical resources to doctors and local hospitals.
The latest plan from the state health department seems to treat all pandemic as if they pose the same risk to public health — interventions are not tailored based on severity. Historical experience attests that some pandemics can be much milder than others, and the CDC explicitly recommends taking severity into account when determining government interventions.
What’s more, the state’s latest plan appears to assume all pandemics will be the severe type. This approach may lead state officials to overreact to a relatively mild pandemic. For instance, the document lists these among its planning assumptions:
“The vast majority of the human population will be susceptible to the novel strain.”
“Higher rates of fatalities will occur.”
“Attack rate will likely be 30% or higher of the population.”
“On average, infected people will transmit infection to approximately two to three other people (R0 = 2).”
“Number of cases seeking care will overwhelm healthcare facilities.”
“Fatalities will exceed the capacities of morgues, and funeral homes.”
These assumptions differ from ones used by the CDC. The CDC’s “Pandemic Influenza Plan,” also published in 2017, assumes pandemic attack rates “could range from 20% to 30%” and does not project health care facilities or morgues to be overrun. It recognizes that the number of hospitalizations and deaths will depend on the severity of the disease. Assuming an R0 of two (a measure of viral reproduction) is also puzzling, considering that the other 2017 CDC report cited by the department’s plan indicates only the most severe pandemics are likely to have an R0 of more than 1.8.
Another problem with this latest plan from the state health department is that in some ways it’s not really a plan at all. For example, it provides no specific triggers or targets to guide when certain interventions should be implemented or rolled back. Nor does it provide details of which specific actions should be taken and when. Instead, these decisions are left to whoever is in office at the time. In other words, by lacking specifics, the plan leaves it to state officials to make these determinations on the fly, which is akin to having no plan at all and similar to Gov. Whitmer's current approach.
For instance, the plans says that the “MDHHS Executive Committee and Subject Matters Experts will make recommendations for the implementation of the community containment measures based on federal, [local health department], and subject matter experts’ input.” It outlines several factors these experts might consider but offers no other guidance. As such, it leaves the question of which specific interventions will be used to whatever these experts decide at the time.
This on-the-fly approach is also evident when the report lists the activities state officials should take during a pandemic. In the "initiation” and “acceleration” phases, no specific intervention is recommended. Instead, state officials are directed to “consult with local health departments regarding the issuance of social distancing orders,” “consider if the situation warrants statewide action and determine the appropriate order(s),” “consult with the governor’s office regarding declaring a state of emergency,” “coordinate community mitigation orders with the governor’s office” and “consider practices discussed in the MDHHS Mass Vaccination Plan and Medical Countermeasure Plan.” So, officials must consult, consider and coordinate, but what action to take is left entirely up to them.
A final problem with this new plan goes back its timing. The scientific evidence on the effectiveness of lockdown-type interventions is limited, as noted by the CDC. And in a report summarizing the research on NPIs, the CDC warns, “Public health authorities should not expect to have information on the effectiveness and secondary consequences of NPIs while the pandemic is ongoing.” Yet, the state health department’s new plan boldly adopts the novel lockdown policies imposed last spring as the new normal for responding to pandemics, even though major questions remain about the costs they impose on society and their effectiveness in improving overall public health.
One shortcoming of Gov. Whitmer’s unilateral control of the state’s pandemic response is that it has been inconsistent and confusing. Some of that stems from her decision to abandon the state’s prepared response and forge her own ad-hoc approach. These latest plans from the state health department appear to cement that way of thinking into the official strategy for handling pandemics in Michigan moving forward.
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