Each day at 10 a.m., Maryland officials update an online dashboard of confirmed coronavirus cases, aiming to keep residents informed about the disease’s spread. The number stood Tuesday at 349, representing a tiny portion of the state’s more than 6 million residents.
But, public health experts say, that figure is woefully inadequate as an indicator of the total number of infections statewide, and poorly reflects both the “community spread” that has been occurring and the coming surge in demand for medical care.
“Everybody knows it’s a severe undercount,” said Dr. Joshua Sharfstein, former Maryland health secretary and vice dean for public health practice and community engagement at Johns Hopkins Bloomberg School of Public Health.
Governors, mayors and other local leaders across the country have joined with public health officials to implement strict measures to halt the spread, from shutting down schools and businesses to asking everyone to isolate themselves as much as possible. But after more than a week of “social distancing,” with the economy on the ropes, President Donald Trump has begun suggesting it’s time to open things back up.
“Our people want to return to work,” he wrote on Twitter.
During a virtual town hall on Fox News, Trump said he wanted people to return to work by Easter, which is April 12, to get the economy moving again.
For physicians and others on the front lines of the pandemic, that advice is alarming. They say more restrictions are likely needed, not fewer. The worst of what this virus can offer — the true scope of the threat — hasn’t sunk in yet, they say, in part because of the nation’s inadequate testing.
“We should behave as if the numbers are much higher, because they are," said Dr. Leana Wen, an emergency physician and former Baltimore health commissioner who now teaches public health at George Washington University. "We just don’t have the tests to prove it.
“We should all be acting as if we have coronavirus, and that the people around us all have it, too."
Officially, more than 50,000 people have been infected in the United States, and more than 600 have died. In Maryland, total confirmed cases ballooned from 107 cases Thursday to the 349 counted Tuesday — a more than 225% increase. Four have died here.
Charles Gischlar, a state health department spokesman, acknowledged that there may be more cases than are being reported “due to the highly contagious nature of the virus and the fact that those infected may not have displayed any symptoms.”
He said the health department is “committed to providing the most timely, up-to-date and accurate information available,” and is working to provide figures on the number of overall tests completed in the state lab — rather than just the number of positive diagnoses, numbers the state provided early on in the outbreak.
Mike Ricci, a spokesman for Maryland Gov. Larry Hogan, noted the department also ordered private labs to report negative tests “so that we get a better picture of the positivity rates.”
Hogan, also chairman of the National Governors Association, has issued various orders aimed at controlling the spread of the virus in the state. On Monday, he said governors across the country are seeking more testing assistance from the federal government — in addition to more ventilators and more protective equipment for health workers.
“There aren’t enough of all of these items, and we’re pushing to get our supply wherever we can, and we’re pushing the federal government to produce more of them, distribute more of them, and hopefully we’ll get some progress,” Hogan said. “There’s been a little bit of progress, but not nearly enough and not fast enough."
Given that early studies have suggested the majority of people who contract the virus show only mild symptoms, or none at all, experts believe the total number of people who have the virus, and are capable of spreading it around to others, is “almost certain to be many times higher than the actual reported numbers,” Wen said.
Given that, Wen, a Baltimore resident, recommended Marylanders ramp up their social isolation. They should stop hanging out with friends, she said, and stop letting their kids play together.
“At this point, we should not be seeing anyone outside our immediate household, unless we must,” she said.
But, in many ways, everyone is still operating in the dark.
“You cannot fight a fire blindfolded,” Tedros Adhanom Ghebreyesus, head of the World Health Organization, said recently. “We cannot stop this pandemic if we don’t know who is infected.”
Said Wen: “There is a profound disconnect between what the president is saying about lifting restrictions and what the reality is on the ground. We are not even close to the peak of the epidemic, and we are still lacking the data to guide us on next steps, because of the lack of testing.”
In the early stages of the pandemic, U.S. officials made several serious blunders when it came to testing, according to a review by The Associated Press. Those include an early decision not to use a test adopted by the World Health Organization, flaws with a more complex test developed by the Centers for Disease Control and Prevention, subsequent government guidelines restricting who could be tested, and delays in getting private companies to ramp up their own testing capacity.
As a result, testing remains extremely limited in many places across the country, with only very ill patients getting tested and diagnosed.
Many of the mildly ill in the U.S. have gone without tests despite being sick, and so-called “community surveillance” testing to identify the asymptomatic among us has been entirely lacking.
Dr. Tom Inglesby, director of the Johns Hopkins Center for Health Security, also at the Bloomberg School, drew widespread attention with a series of tweets Monday night outlining the threat of rolling back social distancing even as the extent of the outbreak remains unknown.
On Tuesday, Inglesby said that without robust testing in place, public health officials have no real sense of the scale of the outbreak — not just in Maryland, but also across the United States.
“We recognize in the order of 50,000 cases in the United States, but we don’t really have a sense of the total number yet because we haven’t been able to do surveillance and we haven’t been able to test everybody,” he said. “We’re only beginning to get a fuller picture.”
Inglesby bristled at the notion of lifting restrictions at a time when the U.S. has nothing else in its arsenal to fight the disease, and not enough equipment to protect the health workers on the front lines. There aren’t enough tests, beds, ventilators or protective masks. There are no known therapeutics to effectively treat the illness, or serology tests to know how many people might have some immunity.
Social distancing orders might be loosened once the country has much if not all of that in place, he said, but “we are so far away from being able to do that right now.”
Sharfstein said that while testing has been “sporadic,” an influx of patients at area hospitals makes it clear there are many more cases in Maryland today than are reflected in the state’s confirmed count.
Specifically, Baltimore hospitals are starting to see more patients who are having trouble breathing, he said. For the worst off among coronavirus patients, it takes hospital intervention to keep them oxygenated — including through the use of ventilators.
Based on the experience of other cities like New York, the early increases indicate far greater demand in the near future, he said.
“We are just seeing the beginning of a wave, so we know that we’ve already got many more cases coming,” Sharfstein said.
To lift restrictions that are keeping people away from others at such a critical point in the advance of the virus and the public health efforts to stop it would be extremely shortsighted, he said.
“It would be a disaster," he said.
The Associated Press contributed to this article.