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Over the next few months it is likely that the coronavirus disease 2019 (COVID-19) pandemic that has surged in New York City, Seattle, New Orleans, and Detroit will move from city to city and state to state. After the initial peak, absent highly effective medical interventions, the US will likely experience outbreaks of lingering disease for months and potentially years to come. As the US enters the next phase of COVID-19, critical questions will involve the nation’s capacity to respond to outbreaks, protect high-risk populations, and limit community spread.
Because of inadequate and continued lack of testing for COVID-19, a depleted and overworked public health workforce, lack of sophisticated integrated public health and clinical health information technology, and substantial cultural issues, the US has yet to implement an effective disease control strategy. Rather, the US has moved quickly from focused isolation and quarantine at a large scale to mitigation, largely focused on a single approach—social distancing. The fundamental question is whether the US can build a more targeted response capability so that the country can return to work, school, and other normal activities.
A key milestone is the fall of 2020. If the initial social distancing and perhaps warmer temperatures reduce the scale of the outbreak this summer, there is a major risk of a resurgence during the traditional season of respiratory viruses. As a possible approach to respond to this challenge, the US should consider suspending the first year of medical school for 1 year and giving the incoming 20 000 medical students the opportunity to join a national service program for public health. Hopefully the vast majority of students would participate. Such a bold approach may be needed to ensure that the US has an adequate response to the next wave of disease and does not enter a prolonged depression that will further adversely affect the health of its citizens.
The program should begin at the start of July. Incoming medical students should spend the month in online training on infectious disease epidemiology, infectious disease control in high-risk settings, and outbreak response. In August, they should deploy to state and local public health departments to enhance the capacity to support a test, trace, track, and quarantine strategy. The federal government should fund this project as a national service effort with a salary for the students and health coverage; it could be part of a larger initiative to engage other students, including those in nursing and public health, as well as out-of-work community members in the national response.
Taking this bold step is justified on health and economic grounds. Today, localities have few resources available to stop community spread other than closing businesses, curtailing large gatherings, and schooling at home. As soon as the novel coronavirus arrives in a community, many are at risk for falling ill, straining the health care system, causing fear, and devastating the economy. Communities must use the next few months to build a robust public health response. It is in part this capacity that has allowed Singapore, Taiwan, and South Korea to respond more successfully to the coronavirus challenge.
Medical students should deploy to state and local health agencies for a variety of roles. One urgent task is to implement rapid testing that informs community surveillance. Even today, only a small fraction of people with suggestive symptoms can be rapidly tested; in some acute care settings, even the sickest patients wait days for the result. Access to testing is so haphazard that it is difficult to draw reliable inferences about incidence, prevalence, and populations at risk. As testing becomes more available—results available within hours—there will be an urgent need to use these data to assess the scope of the epidemic. Whereas the lack of adequate testing and surveillance has been a major weakness of the initial response, it must not be by the fall.
A second urgent task is to enhance protection of high-risk populations, with the goal of reducing the likelihood and effect of outbreaks now occurring in nursing homes and prisons. Medical students should help ensure implementation of critical preventive policies and join teams that swiftly and aggressively respond to infections that occur.
A third role for medical students should be to staff community call centers that offer guidance and services to individuals with symptoms of or exposure to COVID-19. In addition to arranging testing, medical students would ensure that adequate information has been collected from individuals who require quarantine. This information could facilitate efforts to provide food delivery at home, alternative housing if necessary, and additional medical treatment as needed.
There is precedent for such a massive mobilization to address infectious disease. To reduce the spread of Ebola, Liberia mobilized thousands of case workers. China reportedly used 18 000 public health workers in Wuhan alone.1 US public health departments have seen major losses of staff over the past decade.2
Hundreds of medical students have already found ways to help in the response to COVID-19, from offering childcare to health care workers to taking on short-term roles in the health care system.3 Now it is time to formalize an opportunity for future physicians to protect the nation at this critical moment. Paired with other students as well as with community health workers and other local resources, having 20 000 capable medical students as a source of energy and enthusiasm can contribute to a successful response.
Mobilizing future physicians now will complicate medical education in the short-term and the medical workforce 4 years from now. But there are solutions to these challenges. For example, because fewer students means less tuition revenue, the federal government should compensate medical schools for a portion of this lost income.
In July 2025, there will be a gap in medical students available for internships, and in 2026, there will be an excess number of graduates for available residency positions. To address the former problem, licensing authorities that oversee undergraduate and graduate medical education should permit medical schools to offer early graduation to highly capable students, and graduate medical education should make adjustments to reduce the reliance on first-year residents. To address the latter concern, future classes of medical students should be afforded the opportunity for national service before starting medical school, ideally in a broad range of health and social service settings.
There are other challenges. This initiative will be expensive, but potential benefits to economic recovery would be substantial, and financially many would benefit. State and local Departments of Public Health likely do not have the capacity to hire and train a new workforce in such short order. The federal government should direct resources for this purpose to the local level that permit creative partnerships with the private sector to be able to hire and deploy people quickly. As demonstrated in Taiwan,4 health information technology that flows seamlessly between public health and clinical medicine is critically important. In the US, health care information is compartmentalized and siloed in ways that make a national effort to test, trace, track, and quarantine difficult to implement. This problem must be solved quickly to facilitate the response. The logistics of such a program are substantial, and time is short, but without such an effort, the US could well find itself largely shut down this fall.
How and when this initial surge of patients with COVID-19 ends remains uncertain. There is also much unknown about the effectiveness of social distancing, the transmission in the warmer months, and development of new therapies and vaccines. Even as there is hope of a major therapeutic advance, preparation is essential for the likelihood that the disease will continue. To return to work, education, and other activities as soon as possible, the nation should move swiftly to build a robust public health response, drawing upon a workforce that includes future physicians.
Corresponding Author: Howard Bauchner, MD, Editor in Chief, JAMA (firstname.lastname@example.org).
Published Online: April 8, 2020. doi:10.1001/jama.2020.6166
Conflict of Interest Disclosures: None reported.
Additional Information: Dr Sharfstein reported serving as Principal Deputy Commissioner of the US Food and Drug Administration from March 2009 to January 2011.
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Bauchner H, Sharfstein J. A Bold Response to the COVID-19 Pandemic: Medical Students, National Service, and Public Health. JAMA. 2020;323(18):1790–1791. doi:10.1001/jama.2020.6166
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