Author: Ezekiel J. Emanuel, Cathy Zhang and Connor Boyle
Source: The New York Times
Date: April 17, 2020
It’s a start. But it lacks guidance on testing and what do to if the virus comes back.
President Trump’s 18-slide plan for “Opening Up America Again” provides his road map to emerge from the Covid-19 crisis. It acknowledges that the best the president can offer are guidelines — under the plan, governors and regional state coalitions are empowered to make the final determination of what measures to follow, what businesses to reopen and in what sequence. How should we evaluate the guidance?
Let’s start with the good. Mr. Trump offered a three-phase approach recognizing that reopening is going to be a gradual process. The phases are tied not to strict dates — remember “open by Easter”? — but to achieving metrics.
In addition, the relaxing of emergency precautions will be scaled according to the intensity of the problem within a given state or region. The uncertainty that has dominated the national psyche will be abated by tangible milestones like school reopenings (phase two) and allowing visits to senior living facilities (phase three).
The plan also recognizes that not all businesses and facilities pose equal risks of spreading the coronavirus. Distancing and sanitation at a gym is conceivably more difficult than in a bar, though we should be on the lookout for new research to expand our understanding of that nuance. Therefore, different businesses should be allowed to reopen at a pace appropriate to their risk.
Finally, the plan rightly emphasizes vulnerable populations and senior living facilities. These facilities will remain at a high risk of explosive growth in cases until we can achieve widespread testing, vaccination and immunity. So the plan prohibits visits to them until the final phases and requires strict hygiene protocols when visits do occur.
That’s the good. Now the bad. The plan is a failure when it comes to testing, which everyone recognizes as a linchpin in any effort to reopen the country. It certainly assumes that testing will occur: A key metric for each phase of reopening is the trend in coronavirus cases. Accordingly, within a 14-day period there needs to be a “downward trajectory” of either documented cases or the percent of positive tests.
But there is no requirement that states first show that they have tested enough people to establish that the trajectories they are seeing are truly reflective of population-level trends. Overall, testing has been far too low for these trajectories to be relied on. Even after six weeks, barely 1 percent of the country’s population has been tested for Covid-19 and new daily tests have plateaued around 150,000. This is also not enough testing for effective levels of contact tracing.
More important, the plan calls for measuring a relative decline, and not an absolute threshold for very limited spread. So there could be a 14-day decline and yet the number of new cases could still be too high. We need a firm threshold, such as 20 new cases per one million people, that ensures a low number of new coronavirus cases when we start to re-open.
Another big concern with the plan is that, like the current C.D.C. testing guidelines, it still focuses on testing symptomatic people. If we are to stop the spread, the focus has to broaden to asymptomatic coronavirus-infected people who can be unwitting super-spreaders and ignite a resurgence.
We should learn from the experience of the aircraft carrier Theodore Roosevelt, where the disease whipped through the crew even as just a few showed symptoms. This experience indicates that perhaps up to 60 percent of infected people can be asymptomatic. Yet President Trump’s plan proposes very limited testing of asymptotic Americans. The one exception is for “sentinel surveillance sites,” such as “locations that serve older individuals, lower-income Americans, racial minorities and Native Americans.”
Such an approach would not screen asymptomatic essential workers who interact with large numbers of people each day — workers in health care, grocery stores, and the food supply chain. The fact that the gating criteria for hospitals only requires a testing program “for at-risk healthcare workers” misses the point that all health care workers are sources of risk for spreading the virus, regardless of whether they are individually at risk. It would also miss myriad other cases that led to hot spots, such as the now infamous 40th birthday party in Connecticut and the Biogen conference in Boston.
Perhaps the most glaring blunder in these guidelines relates to how businesses are grouped for reopening. Six types of employers are singled out for when to open. One type is “large venues” that can open with strict physical distancing protocols in phase one. Surprisingly, large venues are defined as “sit-down dining, movie theater, sporting venues, places of worship.” But this is a heterogenous group that has little in common.
Indeed, many restaurants and places of worship are not large. Then again, restaurants can space tables widely, and in movie theaters and most places of worship it is possible to have every third seat occupied, without much movement by occupants — while at sporting events, people are present for much longer, and they move frequently to concession stands, restrooms and other sites (not to mention the repeated cheers and songs of fans that spray droplets far and wide).
We need to be particularly careful with these large gatherings. They are economically important but also pose substantial risk for explosive coronavirus dissemination. We have already seen examples: In China, it was the Lunar New Year celebrations; in New Orleans, it was Mardi Gras. But perhaps the most chilling example was that of Lombardy, Italy, where a 40,000-attendee soccer match is now being cited as a major factor behind the region’s outbreak and tsunami of deaths.
Finally, nothing is mentioned in the “Opening Up America Again” plan about how states should handle a resurgence. There is no guidance on defining a significant uptick in cases or how to respond. As Dr. Anthony Fauci mentioned in the press briefing announcing the plan, there may be instances where states must “pull back.” But what does pulling back entail? How will states know when to do this? There is no guidance.
The guidelines also task states with “independently” securing personal protective equipment and key equipment such as ventilators, despite the fact that the federal government has intervened calamitously in this supply chain.
There are many other perplexities to be found: Why are schools, camps and other activities to be opened only in phase two, when Denmark seems to be successfully starting its process of reopening with schools? Why should bars remain closed longer than restaurants? Why isn’t it mandatory to wear masks in public? Why is nonessential business travel only minimized and not prohibited in phase one and can fully resume in phase two?
A lack of decisive action from the federal government has already cost thousands of American lives. It is the widespread actions of the concerned public that have made the worst case scenario less horrific. Now, everyone wants to get back to some semblance of normalcy as quickly as possible. Will Mr. Trump’s guidelines offer people the protections from risk and the reassurance they need?
They are a start. But making Americans comfortable enough to re-engage in commerce and social activity is the key to restarting the economy. Our individual tolerance for risk will determine what daily life looks like in the coming months and how the swift the recovery will be. It is doubtful that Mr. Trump’s guidelines will convince 330 million Americans that the risk to their lives is low enough to send their children to school, return to work, and pick up where they left off.