No politician or public-health expert can say when the novel coronavirus pandemic, and attendant lockdowns and social distancing, will end. But there is a roadmap—actually, a competing array of them—for extricating the United States from social isolation.
In keeping with this convincingly dystopian moment, the hurdles are substantial ones. But if Americans are able to overcome them, the country will veer back toward a recognizable society—with some chilling new features.
Public-health experts surveyed by The Daily Beast said there were three main things authorities need to be able to provide—effectively, affordably, and with quick results—to the American public before it’s safe to send at least some people back to work and into public life. First are millions more diagnostic tests, which can tell if someone currently has COVID-19. Then come antibody tests, which can determine if people recently had it and may have developed enough of the right kind of immune response to offer some protection from illness. Finally, authorities need more robust “contact-tracing” to track who might have been exposed to the virus and prevent them from spreading it further.
A much-discussed problematic and delayed rollout in the United States has kept diagnostic tests expensive, out of reach, and in some cases ineffective. Last week, Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said he doubted every American could be tested anytime soon. But one of President Trump’s top advisers on coronavirus testing, Adm. Brett Giroir, told Bloomberg News in an interview on Saturday that the U.S. is working on rapidly improving diagnostic testing in order to reopen the economy, including both widespread surveillance to catch new flareups and testing of people who have specific symptoms. Giroir said that by May the U.S. will be in the “ballpark” of the diagnostic capacity it needs.
According to William Haseltine, a former Harvard Medical School professor and the president of the global health think tank ACCESS Health International who recently chaired the U.S.-China Health Summit in Wuhan: “It should be a hand-held device for $5 a pop.”
“That could be done by the end of the summer,” he told The Daily Beast. “We could do it if our economy depends on it.”
Of course, elsewhere around the globe, tests have been performed by the hundreds of thousands—in other words, far more per capita than the United States. And many experts still say it’s necessary for the U.S. to reach that capacity, including those at the right-of-center American Enterprise Institute who put forward a plan this month that would require about 750,000 tests per week in the U.S.
As for antibody testing, Fauci said last week the American public was “days” away from rapid antibody tests for COVID-19, which received emergency authorization from the FDA on April 4. But on Friday, New York Gov. Andrew Cuomo noted that re-opening the state would require the creation of “millions and millions” of antibody tests that don’t exist.
As Haseltine explained, however, there is precedent elsewhere for creating cheap and effective antibody testing on such a large scale. For example, he noted, the Egyptian Ministry of Health used so-called serology tests to screen more than 60 million citizens over the age of 12 for hepatitis C, diabetes, hypertension, and obesity. Those tests cost about 50 cents per person, are conducted using blood from a simple finger-prick, and the results were available in as little as five minutes, he said.
But there are two main snags with the antibody tests currently approved by the FDA. The tests are coronavirus-specific, but not necessarily specific to the infection that causes COVID-19, according to Haseltine. That means that even if most people who’ve survived the virus are able to develop an effective immune response to it, some antibody tests being rolled out in the U.S. might not be able to tell if you’ve had COVID-19 or recently had an unrelated cold in the same family of viruses, he explained.
People who are still holding out hope for returning to packed sporting events and boozy brunches are probably going to be disappointed.
“One-third of colds are coronavirus,” Haseltine added. “This test isn’t going to be foolproof.” What’s more, experts are still uncertain that people who recover from COVID-19 can create enough of an immune response to keep them protected from reinfection.
Even with adequate testing and a relatively strong trend toward immunity from the previously infected, a second wave of infections could grow out of control without robust and meticulous monitoring of infections as they appear.
“We want to get back to work, but you’ve got to do extensive contact tracing and mandatory isolation for 14 days of everybody who has tested positive,” said Haseltine. “These are real examples of what’s happening in Wuhan today. They’re getting back to work, but they’re getting back to work really carefully.”
But Irwin Redlener, director of the National Center for Disaster Preparedness at Columbia University and an expert on U.S. readiness for pandemics, pointed out a significant problem: The U.S. has “decimated our public-health system over the last decade.”
In other words, there is reason to doubt there are enough health-care workers to provide the quantity or quality of contact-tracing the country needs. It might be possible, he said, to outsource that work to private companies. Timothy Brewer—a professor of epidemiology and medicine at UCLA who has served as an adviser for the World Health Organization, CDC, and National Institutes of Health—pointed to the Israeli health ministry’s decision to hire the medical students who’ve had their classes canceled to do contact-tracing as a potentially worthy precedent.
There are other hurdles, too. It’s important to ensure hospitals around the country can handle a surge of cases without resorting to crisis standards of care, provide enough personal protective equipment for all health-care workers who could be exposed to cases, and—as the American Enterprise Institute plan notes—there should be a sustained drop in cases for more than 14 days before any social-distancing guidelines in hot spots are loosened.
Assuming all these obstacles are overcome, people who are still holding out hope for returning to packed sporting events and boozy brunches are probably going to be disappointed. At least for a while.
Most health experts interviewed for this story agreed on two main points: The loosening of social-distancing measures has to be done slowly and carefully; and public gatherings—like concerts, professional sports, movie theaters, and especially cruises—will be the last to return.
The lockdown in Wuhan, China—the original epicenter of the infection—lasted more than 10 weeks, and only relented after new cases slowed to three new infections in three weeks. (As always, it bears mentioning that there are reasons to be skeptical of official tallies from Beijing.) In the port city of more than 11 million people, many—but not all—civilians are now allowed to leave town, 94 percent of businesses have reopened, and the public-transportation system is running, The New York Times reported. But schools remain closed, many businesses have not yet reopened, and authorities still regulate people going to and from their homes.
Based on the progress in Wuhan and in Italy, Americans could be coming out of shelter-in-place in “more than a month but less than four months,” Brewer suggested. To paint a clearer picture for New Yorkers, for example, he said to expect to be back in the office by the end of the summer, by which time Manhattanites might even be able to “throw a small party, depending on your age and demographic—and the age and demographics of the individuals who will be coming.”
The American Enterprise Institute’s plan recommends a phased reopening of businesses with an emphasis on telework, distance learning, and continued personal social distancing, along with an indefinite ban on gatherings of more than 50 people.
Arnold Monto, a professor of epidemiology and global health at the University of Michigan who has advised both the World Health Organization and the Defense Department on communicable diseases, also predicted a gradual reopening. He teased a scenario where people who can work from home keep doing so as long as possible, while others who cannot begin commuting to work. Monto noted there are plenty of jobs deemed “nonessential” that don’t require close contact within six feet, including lawn maintenance and gardening. It would also be smart to keep all non-essential travel on hold, since that was an issue in China, where local transmission was contained until travel between cities brought in new waves of infection, he said.
Brewer said politicians making these decisions in the coming weeks will probably choose to release from shelter-in-place restrictions those who are younger and who don’t have underlying health conditions—before those over the age of 65 with co-morbidities. Likewise, visits to assisted-living and skilled nursing and eldercare facilities with high-risk populations will probably be on hold for a long time to come.
“But how you put that into effect is really difficult,” said Monto, noting that some flare-ups following loosened social-distancing guidelines are “inevitable.”
Redlener agreed that sending people back to work “piecemeal” from different sectors or parts of the country “sounds like a good idea,” but that it might not be practical.
“I have trouble imagining what it looks like,” said Redlener. “For one thing, who goes back to work first? And how is it justified?”
Despite significant concerns about privacy and surveillance, Beijing last month implemented a color-coded QR system to determine which Chinese citizens can travel freely outside of their homes. A green code shows the user is not under quarantine and can move around the city freely; it’s updated nightly.
That approach, for reasons that have been written about at length elsewhere, might not work in the United States. Any system of meticulous testing and tab-keeping and temperature-monitoring, as has become ubiquitous at businesses and venues in China, would need to account for America’s libertarianism and its unique legal system.
“As a public-health professional, I think it would be a good idea to have to show proof-of-test results in order to go to a sporting event or restaurant, but as an individual, it’s a very intrusive idea,” said Redlener. “These are very fundamental struggles that we’re going to have to go through.”
And even with that kind of meticulous testing, people will need to be more careful than ever.
“The common cold is no longer the common cold. If you start getting sick, you need to get tested immediately and rapidly,” he continued. “If they’re negative, they go home and stay home until they’re symptom-free. If they are positive, then we have to do aggressive contact-tracing.”
Of course, that’s just one behavioral change out of countless others that will be necessary after this pandemic.
“We still take off our shoes when we go to the airport, and how many years has Osama bin Laden been dead?” Brewer said, noting that there will likely be more hand hygiene stations in public places, limited use of reusable grocery bags, and more mask-wearing in public in the U.S., like has been common for years in Hong Kong and Tokyo.
But at least for a while, even once infections drop in the U.S., everyone may need to get comfortable with some level of uncertainty.
“At any moment, one person could start the whole thing over again,” said Haseltine. “That’s why it’s going to be a long time before we can go back to normal. The danger is that we’re going to run out of patience and political will.”