Q&A With … Randall Williams, Missouri Department of Health and Senior Services

Randall Williams, who is the director of the Missouri Department of Health and Senior Services has been giving regular updates about the impact of COVID-19 on Missouri.

Q. At this point in the circulation of the virus, is real containment possible, or will the primary goal going forward continue to be managing the spread to minimize impact on health-care resources?

A. The word we use is mitigation, not containment. Our goal there is to get the R-naught value, the measure of the infectivity of the virus, to less than 1. The intrinsic value for this virus is 2.6. If the flu is at 1.3 and you have the flu, on average you can infect 1.3 more people. So this is twice that, and in any epidemic, you’re trying to get that value to less than 1, which means infections will tail off. When we look at our data from Missouri, our R-naught across the state is less than 1, and in St. Louis, it’s right at 1. At that value, because of the things we’ve done, it appears that our mitigation is working.

Q. Does the state’s data on COVID-related fatalities suggest to you that, going forward, the best management strategies should focus on the groups facing the highest risk (elderly, those with co-morbidities, etc.)?

A. As the governor has said, COVID is not going to go away on May 4 when the restrictions start to lift. Our strategy very much depends on what we call “box in.” We use testing capacity, case contact-tracing capacity, and when have outbreaks, whether in a nursing home, community or specific geography, we can go in, as we did in the Camden County meatpacking plant and Jefferson County nursing home last week, or the homeless shelter in St. Louis over the weekend; we’re already doing that. So you go in with comprehensive testing and test everybody.

Q. What are you learning about managing this health threat as it evolves?

A. When the disease started off, the first thing we noticed was the propensity for co-morbidity and mortality in the the elderly, then those with one disease. Then we learned it had a real proclivity for confined spaces—ships, nursing homes, prisons. Then we learned that African-Americans, and then health care workers were at greater risk; something like 10-14 percent the first responders have been infected. We are constantly learning from around the country and from our peers.

Q. Do you have enough data yet to reach any preliminary conclusions about why the St. Louis area has been so much more affected, in terms of case/death counts, than Kansas City?

A. It’s an interesting question. Our first case was in St. Louis County, and it was travel-acquired. It’s a very big county, very spread out, so given what we know about population density with this illness, what is it about that area that would make it different? We’re still looking at that. We have to get more information from surveillance, checking asymptomatic people in communities hit hard. This is most prevalent in largely urban areas, and I give a lot of credit to the mayors and county health departments for keeping the numbers low in Missouri. It’s been a true state, county, hospital and provider team effort.

Q. What’s your reading on the trend lines for overall cases, hospitalizations and fatalities? Do you sense that we are, as the IMHE estimates, past the peak in Missouri?

A. You may pay a lot of attention to those national models and estimates, but we don’t. We use Missouri data. At the height of this, we did more testing than any of the eight border states except Tennessee, on a per-capita basis. We’ve always put a premium on testing. But our case-doubling rate is now up to 20 days, and the number of new cases is declining. By all indications, we are past the peak.

Q. What can you tell us about efforts by the state, going forward, to promote the social behaviors that are attributed to helping flatten the demand curve on health-care resources to this point?

A. As Gov. Parson says, at the end of day, with 6.1 million people, we can’t police all of them or monitor all their behavior. This depends on people doing the right thing, and they have, to their great credit. On May 4, they have to continue to do that. There will be a new normal, whether that’s using the hand-sanitizers, social distancing, all those things. Like the governor says, the hardest thing will be not shaking hands. But people have gotten us to where we are now, and we have confidence they will settle into this new normal.