If there’s one thing people agree on – even as they debate the government’s coronavirus response – it is this: We can’t do this forever.
The nationwide shutdowns, the home quarantines, hospital shortages, layoffs, deaths and infections. All seemingly without end. So what exactly is our next step?
The country’s response thus far has been reactive – always one or three steps behind the virus. And it has been uncoordinated – a patchwork of state-by-state, competing and at times contradictory decisions. Now health experts are pressing for a national long-term strategy to combat the virus and eventually get back to normal.
With the White House’s current 15-day guidelines on social distancing expiring early this week, Vice President Mike Pence said on Saturday night that the covid-19 task force would bring its recommendations to President Donald Trump in the coming week on whether to ease the recommendations and reopen the economy. What Trump decides in coming days could have sweeping impact on the economy, his presidency, and the lives of millions across the country. His comments about reopening parts of the country by Easter, April 12, has worried many public health experts who warn the move could cost more lives.
In recent days, epidemiologists and infectious disease specialists, as well as former top agency officials, have rushed to put out their own plans – by publishing preprint papers online and sharing ideas on Twitter and in op-eds. In a recent flurry of proposals, a consensus of sorts has begun to coalesce around several key ingredients for an American strategy to move forward while minimizing human and economic casualties. They include mounting a large-scale contact tracing effort, widespread testing, building up health care capacity before easing restrictions, making future quarantines more targeted, and allowing those who have recovered and have some immunity to go back to work.
The latest proposal is a 19-page plan with a step-by-step timeline, with clear benchmarks states and regions would need to meet to safely move forward to the next step. The plan was published Sunday by the American Enterprise Institute. Its lead author – Scott Gottlieb, former Food and Drug Administration commissioner in the Trump administration – has been acting as an informal adviser to the White House. His collaborators include Mark McClellan, a former FDA commissioner from the George W. Bush Administration; Caitlin Rivers, an epidemiologist at Johns Hopkins Center for Health Security; and other leading policy experts and epidemiologists.
“People feel anxious about the future and you need to have milestones to show people how their lives are going to improve,” Gottlieb said in an interview late Saturday. “The goal is to outline a plan that will allow a gradual return to a more normal way of life without increasing the risk” that the epidemic will resurge.
Most economists and health experts say there is no way to restart the economy without addressing the underlying problem of the coronavirus. As long as the pandemic continues to spread, the markets will be in turmoil and any businesses will struggle to stay open, they say.
“The question is once you take your foot off the pedal, what happens then?” said Michael Osterholm, director of University of Minnesota’s Center for Infectious Disease Research and Policy.
Like other experts, Osterholm has argued in a series of op-eds and interviews that instead of giving false reassurances and deadlines, the White House should tell people the hard truth about the current situation and a coherent strategy they can work toward. “The social distancing, being stuck at home, the deaths we’re going to be seeing. People want to know what it’s for. That there’s a plan.”
Similarly, the road map Gottlieb’s group outlined stresses the need to move away from the current decentralized system and “toward more coordinated execution of response.”
The report was co-authored by Lauren Silvis, an attorney who was Gottlieb’s chief of staff at the FDA, and was reviewed by prominent experts including Thomas Inglesby of the Hopkins Center for Health Security and Trevor Bedford, a computational biologist at Fred Hutchinson Cancer Research Center.
The plan divides coming months into four phases and sets “triggers” for states to move from one phase to the next. Given the uneven spread and stages of outbreak, not all states would move through the phases at the same time. While overall the peak of the epidemic may occur in late April or early May, the timing may be different in different states. And New York, which is the current epicenter, may see a decline in infection rates as other states have an increase.
With most of the nation now in phase one of the epidemic, the goal should be a sharp increase in hospital critical care beds and an increase of testing to 750,000 people a week to track the epidemic – a number Gottlieb said could be achieved in the next week or two. For a state to move to phase two, it should see a sustained reduction in new cases for at least 14 days, and its hospitals need to be able to provide care without being overwhelmed.
“The reason we set it at 14 days is that’s the incubation period of the virus,” said Rivers of Johns Hopkins. “That way you know the downward trend is certain and not because of a holiday or blip or some other delay in reported cases.”
States that have moved into phase two would begin gradually lifting social distancing measures and opening schools and businesses, while increasing surveillance. The key goals thereafter would be accelerating the development of new treatments and deploying tests to determine who has recovered from infection with some immunity and could rejoin the workforce.
Phase 3 occurs when the nation has a vaccine or drugs to treat covid-19 in place and the government launches mass vaccinations. Phase 4 involves rebuilding the nation’s capacity to deal with the next pandemic by building up its scientific and public health infrastructure.
Trump has repeatedly returned to strategies of bans and movement restriction. On Saturday, Trump indicated he might announce a federally mandated quarantine on the New York metro region, forbidding people to leave the New York tri-state area.
His comments quickly prompted questions about whether it was feasible or legal. New York Gov. Andrew Cuomo called a possible quarantine “preposterous,” while New York Mayor Bill de Blasio said he wasn’t “sure what the president means.”
It was unclear whether Trump was seriously considering the New York quarantine or whether it was an off-the-cuff pronouncement. Two White House officials said the idea was spurred by a conversation Saturday morning with Florida Gov. Ron DeSantis, who complained about people from New York pouring into his state. Aides spent the day warning the president against it, explaining that it would be impossible to enforce and could create more complications, the officials said, who spoke on the condition of anonymity.
For weeks, World Health Organization officials have stressed such lockdowns are only helpful for slowing down the virus and buying time to deploy more targeted and comprehensive measures, which the U.S. has not yet done.
Mike Ryan, WHO head of emergency programs, recently urged countries to focus on finding and isolating infected people and their contacts. “It’s not just about physical distancing, it’s not just about locking down,” he said.
Many experts’ recent proposals for a U.S. strategy have similar stressed the importance of large-scale contact tracing – because it was a cornerstone for successful efforts like South Korea and Singapore.
Some epidemiologists in the past considered contact tracing on large-scale impractical and unhelpful once an outbreak has become widespread in a community. But as countries have shown success with it against this coronavirus, that thinking has changed.
In a recent paper, Marc Lipsitch, a leading epidemiologist at Harvard University suggested that while such contact tracing is “impractical now in many places but more practical once case numbers have been reduced and testing scaled up” and “could alleviate the need for stringent social distancing to maintain control of the epidemic.”
South Korea had already honed this ability during an 2015 outbreak of the deadly MERS coronavirus. Singapore deployed its police force to do the work, drawing on digital footprints with security camera footage and credit card records.
In the U.S., that task has fallen to county health departments – weakened by decades of budget cuts and lacking the staffing and ability to mount such a response. Rapidly building up that capacity – either with community volunteers or short-term hires – will be crucial in coming months, said Rivers of Johns Hopkins. “If you build capacity up and bring cases down, it starts looking a lot more possible.”
Many proposals tackle the problem of the tanking economy. The Gottlieb-Johns Hopkins plan, for example, calls for widespread use of blood tests to identify people who have had the infection and now are immune – called serology testing. People who are immune could return to work, or take on high-risk roles in the health care system and help people, especially the elderly, who are still quarantined at home.
Such serology tests have not been deployed before like this on such a large scale. But during Ebola outbreaks in Africa, survivors were often the ones who provided care, watched over the children of sick patients and buried the dead.
One challenge unaddressed by most proposals and op-eds, however, is how to get such detailed plans adopted by the White House, whose response has weighed down by infighting and unclear leadership ping-ponging in recent weeks among Trump, Pence and health advisers like Anthony Fauci and Deborah Birx and others.
Pence said on Saturday night that the covid-19 task force would bring its recommendations to Trump in the coming week on whether to ease social distancing and reopen the economy.
Health officials and scientists involved in the federal response, especially from the Centers for Disease Control and Prevention, have fought to be heard while straining to avoid offending Trump, who bristles at being publicly contradicted, undercut or overshadowed by praise for ideas or people beside himself, according to people who spoke on the condition of anonymity about sensitive deliberations.
“While the president has said he’d like to open the country up in weeks not months, we’re going to be bringing that data forward to him,” Pence said in an interview with Fox News. “Ultimately, the president will make a decision that he believes is in the best interest of all of the American people.”
On Thursday, Trump unveiled a plan of his own, though scarce in detail. He said he planned to help communities ease their restrictions and reopen for business by using on “robust” surveillance and categorizing counties across America into three “risk levels” – low, medium and high. More details are likely in coming days, White House officials said.
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The Washington Post’s Josh Dawsey contributed to this report.