Several states are now seeing a surge in new Covid-19 coronavirus infections and hospitalizations. And the states with more alarming outbreaks — Arizona, North Carolina, South Carolina, Texas, Utah, Arkansas, Florida, and Tennessee — generally saw few cases early in the pandemic.
Many of these states have started to relax the restrictions on movement, businesses, and public gatherings that were meant to control the spread of Covid-19. But with infections rising, there will be more illnesses, deaths, and financial hardships for people who have already suffered immensely from this pandemic.
If cases continue to rise and threaten to overwhelm the health system, officials may be faced with a daunting prospect: another round of shutdowns, requiring businesses that have reopened to close, public gatherings to be banned again, and stay-at-home orders to go back in effect.
Some local officials are already talking about this possibility. The city of Houston, Texas, for instance, is weighing another stay-in-place order. (It may ultimately be prohibited from having stricter rules than the state government.)
Thanks to several studies, including two recent scientific papers in the journal Nature, there’s now more certainty these measures dramatically lower the case count and save lives. However, the shutdowns also drove a massive spike in unemployment and caused huge social strains as people were forced to stay apart.
Asked about the prospect of further lockdowns, Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, told Science Friday last week it depends on how well other public health strategies are deployed.
“Whether those infections turn into a real resurgence of infections and a rebound will depend on how effectively we’re able to identify, isolate, and contact trace,” Fauci said.
Other public health experts are debating the viability of additional lockdowns, noting it may be harder for leaders to muster the political will for them now, and that citizens may be less likely to comply with them.
I see no viable path to further lockdowns. We need to employ targeted public health interventions. But states aren’t even doing case isolation well, much less contact tracing. Little follow-up for positive cases. People need support to stay home. https://t.co/SpKSsyI8uO— Jennifer Nuzzo, DrPH (@JenniferNuzzo) June 15, 2020
What’s clear is that it will be difficult to get quick, satisfying results from shutdowns at this stage of the pandemic. And while there are other ways to protect public health that don’t require such sacrifices from the public, they require investment, coherent public messaging, and political will. Unfortunately, it doesn’t appear every state has these elements in place.
The US is in a much different place than it was at the start of the Covid-19 pandemic
The United States is now the epicenter of Covid-19, with 2.16 million confirmed cases and 118,000 deaths as of June 16.
This growth is evident in states like Arizona, now a hot spot for the virus with daily cases climbing rapidly in the last two weeks. Will Humble, former director of the Arizona Department of Health Services, said the shutdowns worked when they were implemented on March 31. Arizonans largely complied with stay-at-home orders. Businesses closed. People maintained social distance.
But there was little transmission at that point. “The first stay-at-home order was done when we just had a couple hundred cases a day,” Humble said. Then on May 15, Arizona Gov. Doug Ducey allowed the order to expire, replacing it with an executive order that suggested guidelines for how people should behave, but no enforcement. It’s likely that this relaxation contributed to the rise in cases.
“We’re blowing the doors off now with 1,500. ... We’d be going into a stay-at-home order under very different circumstance than back in April,” Humble said.
A reimposition of shutdown measures at this point, if they were obeyed, would still reduce the number of new infections. But that reduction would be in proportion to a higher baseline. New cases would drop, but it would take much longer to reach the levels seen after the first round of shutdowns.
When starting from a higher number of cases, there is more transmission baked in. For instance, there will likely be more cases of household spread among family members under a stay-at-home order. And when there are a higher number of overall infections, there are likely to be even more undetected infections that may continue to worsen the pandemic.
And as states saw during their first brush with shutdowns, it can take a while for pandemic control policies to show up in the data. “We can expect those lags and timings would operate in a similar way,” said Joshua Salomon, a professor of medicine at the Stanford University School of Medicine who studies disease models and public health interventions. “It takes a few weeks after you change people’s interactions and contacts for that to translate into a reduction in the number of cases.”
Perhaps the biggest unknown for a second shutdown is how well people will adhere to the orders. Already, people in some parts of the country are gathering en masse, flocking to reopened businesses, and flouting guidance to wear masks in public places.
“We are starting to notice a lot of people across South Carolina are not doing the social distancing or not avoiding group gatherings and wearing masks in public the way, especially, that they were earlier on,” Brannon Traxler, the physician consultant for the South Carolina state health department, told ABC News. Public officials are also facing intense political pressure to ease restrictions.
Hannah Druckenmiller, a doctoral student at the University of California Berkeley, co-authored a recent paper looking at the effectiveness of shutdown measures. She and her team found that across the US, such tactics averted 4.8 million more confirmed cases of Covid-19 and up to 60 million infections in total.
But the results also showed that these policies had different effects in different parts of the world because some governments took the policies more seriously than others.
“This is likely a result of the fact that populations have different cultures and governments enforced the policies to varying degrees,” said Druckenmiller, in an email. “One interpretation of this result is that if a second round of lockdowns was less strictly enforced and had lower levels of compliance, these containment measures may not be as effective as they were in March and April.”
With states taking so many different approaches to the pandemic, however, the US is likely to experience a patchwork of different outcomes from further school closures, public gathering bans, and shelter-in-place orders.
There are alternatives to shutdowns, but the US hasn’t invested in them enough
Economic and social shutdowns are effective, but they’re expensive. They weren’t meant to stay in place indefinitely, but were aimed at slowing the spread of the virus to prevent hospitals from being overwhelmed with patients.
The more targeted strategy for containing Covid-19 is testing, tracing, and isolation. With a robust system of testing, health officials can identify people who are infected and spreading the disease, even before they feel sick. Then they can trace the contacts of the infected to test other people who may have been exposed. And the people who test positive can be directed to isolate themselves. All the while, the general public should maintain social distance and minimize exposure as they take calculated risks in going about their lives.
Such an approach would break the chain of transmission of the virus. It would also only require a handful of people to stay home rather than large swaths of the population. But it demands a lot of infrastructure to deploy tests and trace contacts, and it takes time to set up.
“Shutdowns really had two goals. One was to stop the uncontrolled spread, which they did,” said Salomon. “The other was to try to buy us time to set up the public health infrastructure to do testing and tracing and isolation at scale. And we really failed to make use of that time.”
Another round of closures and stay-at-home orders could still be availed to build up the testing and tracing capacity. The more testing and tracing is available, the less strict shutdowns need to be. And building a system for testing millions of people would still be cheaper than an indefinite pause of the economy.
At this point in the pandemic, public health officials also have a better understanding of the spectrum of risk for the virus. Rather than issuing blanket orders to stay home, more nuanced guidance about what kinds of public spaces are safe and what precautions are necessary could ease the acceptance of pandemic control measures. But that requires careful and nuanced public messaging, and given the mixed messages the public has received on tactics like wearing masks, health officials would have to rebuild trust.
“What we really want to do is get as much benefit as we can from lockdowns in a way that’s more targeted and doesn’t demand as much sacrifice,” Salomon said. He added that policies like paid sick leave and building up work-from-home capabilities would also be important steps to helping people avoid unnecessary exposure to Covid-19.
As for when states can relax, that remains a fraught question. Some of the guidelines from the federal government for reopening have been confusing, and some states have gone ahead and established their own.
More recently, the Centers for Disease Control and Prevention put out a list of best practices to reduce Covid-19 risk as shutdowns relax. Measures include wearing masks and maintaining distance from other people.
However, with cases spiking in several states, it may still be too soon to think about relaxing, and efforts may still be needed for containment. But with the most blunt yet effective public health tool losing strength, it’s more urgent than ever to fight the pandemic without such drastic measures.