The failures of the United States’ initial response to the Covid-19 pandemic are already well established: Officials were too slow to recognize the threat of the disease and too slow to get diagnostic testing in place, and were ill prepared for the strain on our health care system.
But now, largely, Americans are doing something right: social distancing.
The outright lockdowns of movement in some cities, as well as the less severe policies in place across the country, can slow the spread of the pandemic. And per at least one poll, people are, by and large, complying.
Frustratingly, though, we must be patient in our isolation. The impacts of social distancing lag in case-count data and may take a few weeks to show up. Right now, there are infections out there, in the public, that were seeded long before these orders came into effect. It can take 10 days or more between when a person is infected and when they show symptoms — during which they can spread the virus to others.
The social distancing measures in place also aren’t airtight, so these infections will still seed some others. And just the cases that are already out there are expected to overrun hospitals.
It’s important to recognize it could be months until it's safe to lift social distancing restrictions. And the timeline might vary depending on where you live and when the virus strikes the hardest.
We need social distancing because it slows the spread of the disease to manageable levels. When that happens, we can move to a more sustainable mitigation strategy. But we’ll need to be careful. Just look at Hong Kong: After a month of strong control measures, including social distancing, cases are on the rise again, perhaps fueled by residents returning from abroad.
Know this: Ceaseless social distancing is not the only way to end this outbreak. And President Trump has painted a false choice between saving lives and saving the economy. We can find a balance. It’s just that the current orders of social distancing would need to be replaced by a comprehensive, extremely ambitious plan.
Epidemiologists and pandemic experts have been telling me about what it would take to end social distancing safely while fighting the spread of Covid-19. It isn’t easy. It will require an immense amount of leadership, coordination, and more sacrifice. It would take a sort of moonshot-level effort. But the tactics they outline aren’t unfamiliar. They’re textbook epidemiology — they just need to be scaled up to a level never really seen before.
“We really do need a Manhattan Project effort to get this stuff in place in really a two- or three-month period,” Jeremy Konyndyk, a senior policy fellow at the Center for Global Development, says.
We need social distancing across the country, and we need to keep it in place for some weeks, if not months, to buy time. If social distancing works, is enacted broadly, and is kept up, the number of new infections could decrease. It would give us a pause in the action, to potentially move on from social distancing to a more targeted pandemic strategy. Right now is the time to get plans ready so when that pause comes, we can make things right.
Why the US can’t open back up soon: It’s too dangerous
It’s understandable that some — maybe most — people want life to go back to normal already. Trump was anxious too, and until March 29 was saying he hoped to reopen the country by Easter, April 12.
That is “a nightmare scenario for epidemiologists and health care workers,” says Tara Smith, who studies emerging infectious diseases at Kent State University. “Imagine the mixing of populations that would happen at Easter if given the ‘all clear’ — people who may be carrying the virus without knowing it, hugging their loved ones, spending hours in close contact, and then everyone going back home afterward.” Luckily, Trump announced he would extend the federal social distancing guidelines until the end of April, at least.
Although data show that all age groups and people without preexisting risk factors can fall critically ill from the disease, social distancing isn’t just for you. It crucially protects vulnerable people from the disease. Without it, they become vulnerable again.
“If we all just went right back to how things were before, transmission would start again with the same intensity,” says Caitlin Rivers, a professor at Johns Hopkins Center for Health Security. “It’s hard to experience so many restrictions, and so many hardships, and not feel like it’s not working. We need to recognize that we are doing the right things. You just have to be a little bit patient.”
From sledgehammer to scalpel
It’s worth remembering why we’re in this situation. “The facts remain that we wasted a lot of time in terms of ramping up testing,” Saad Omer, director of the Yale Institute for Global Health, says. Testing in an outbreak provides two functions. One is to diagnose those who are sick. The other is surveillance: to see where the virus may be lurking, especially in cases where symptoms are mild or don’t manifest at all. The US has barely had enough testing capacity to test the sickest, let alone the capacity to do surveillance. Many doctors are telling patients with milder symptoms to just stay home and not get a test.
“Social distancing is basically a sledgehammer,” Konyndyk, who has worked on past outbreaks, like Ebola, says. “You’re just stopping everything and hoping that in the process you will also slow transmission.” What we need to do, he says, is turn that sledgehammer of social distancing into a scalpel: widespread testing and contact tracing.
“The classic epidemiological approach to controlling disease is not to shut down society; it’s to target the people you know to have the disease and understand who they’re spreading it to,” Konyndyk says. “We can’t do that right now because we don’t have enough testing to know who has the disease.”
Not only do we need more testing, we also need testing that can be completed within minutes. “I would just be so happy if we had rapid diagnostics,” Saskia Popescu, a hospital epidemiologist in Phoenix, Arizona, says. “If you’ve ever been to an urgent care, when they do a flu test, in many cases it takes, like, 10 minutes. So if we can move to more of a rapid diagnostic where it’s a very, very quick turnaround, then we can make sure that those people go home and isolate themselves.” Currently, it can take days to get a diagnostic test back, and people may not be sure of what to do while they wait.
These rapid tests are in the works: Recently, the FDA approved one that can give results in five minutes. But we’re going to need other kinds of testing, too, like serology — testing of people’s blood. That way, we can figure out who has already had the disease and is now immune and can safely return to be in contact with others in society. (Though scientists still need to do more work in determining what immunity looks like in any given person.)
The US needs to figure out who is going to do the testing and tracing
“The first piece of the moonshot is what we’re doing now, and will hopefully sustain, which is mass social distancing to do the sledgehammer to bring down the numbers,” Konyndyk says. “Once you bring down the numbers back to a manageable level,” he says, we need to go back to some textbook epidemiology.
Once there’s widespread testing, there needs to be a huge team of public health workers in place to trace the contacts of those who test positive. Everyone who tests positive or who has come into contact with someone who tests positive then needs to be put into quarantine or isolation, to not spread the virus any further. This is how authorities routinely beat outbreaks — even of incredibly infectious diseases like measles.
In South Korea, this work was aided by technology. Authorities used GPS data from people’s cellphones to figure out whom they may have been in contact with. The GPS data may prove more reliable than their memory. “We need to take a good look at what South Korea has done, and what people here are willing to accept as far as some of those intrusions of public health into their normal lives, their privacy,” Smith says.
Also helpful would be “a forecasting function for the ebb and flow of the disease at the community level,” Konyndyk says. The country already has tools to forecast flu outbreaks. We could adapt them for Covid-19. With such a forecasting tool, “we could see an upsurge in cases, and then dial the social distancing back up,” he says.
Even aided by technology, this work would require an enormous number of workers. “It’s very labor-intensive to find contacts of people who are sick,” Rivers says. “A part of what we do with contact tracing is to check on them every day to see if they have become sick.” Keeping some measures of social distancing in place might make this work easier, too: If people have fewer places to go, fewer crowds to assemble in, there will be fewer contacts to track.
Konyndyk suggests this effort would take “tens of thousands of people, maybe more.”
So these are the questions our leaders need to be asking now: Who will do this work? Will it be the National Guard? Could we employ and train laid-off workers from the concurrent economic crisis to provide support? “I think there’s lots of options, but starting with the vision and the strategy is kind of where we should begin,” Rivers says.
And right now these experts don’t see that vision coming from the federal government. By and large, the response to this outbreak is in the hands of state and local leaders. But “you want the federal government laying out, ‘Here’s the strategy, here’s the path,’ and getting the ball rolling,” Konyndyk says.
And even in this aggressive test-and-trace scenario, there could be many disruptions to our lives. It could mean a lot of people still under quarantine orders. Some level of general social distancing might also still need to be put in place. Perhaps, for example, schools could reopen but adults would still be encouraged to telework, and sporting events and other mass gatherings would be canceled. It’s not the case that everything could go back to normal. It’s the case that we could let some things go back to normal. Social distancing is a treatment we’d need to gently taper off. (We’d also need to be vigilant about the possibility we still could import new cases from abroad.)
Researchers at the Imperial College of London suggested another way to taper off in a paper: pulsing. That is, we can relax social distancing policies when hospitals seem to be managing cases, and ramp them up when ICU beds are in short supply. But this isn’t ideal. “How would life look like if went on, and then we went off, and then on, and off, I think it would be hard to envision how life would unfold under that scenario,” Rivers says. This likely wouldn’t end the pandemic, but it would spread its pain over a longer period.
In any case, we’ll probably have to take a step-wise approach off social distancing and see how we can best balance it with returning to some small slice of normal life. In time, we’ll learn how to achieve that balance. For now — and because there are just so many things about this virus that are still not known — we need to stay put.
Still, you might be wondering: How long might this all take?
Rivers, along with former FDA Commissioner Scott Gottlieb and other co-authors, released a plan Sunday on how to ease off social distancing. The plan has several phases: Phase one is slowing the spread through social distancing, while ramping up testing capacity, and ensuring hospitals have the equipment they need. In phase two, social distancing restrictions ease while public health workers continue to track and isolate cases.
But it will take a lot to get there. The authors argue these decisions need to be made on a region-by-region basis: Phase two should only begin after 14 days of sustained case reductions in an area, and only after testing capacity is dramatically increased. Even in phase two, they stress, if cases go up again, we’ll need to go back to severe social distancing. Before there’s a vaccine, we’ll have to remain vigilant.
We still need drugs and, ultimately, a vaccine. Patience is needed here, too.
The ultimate goal in stopping a pandemic is a safe and effective vaccine that can prevent people from getting the virus. The good news is that these are already being tested. The bad news is that it could take a year or more to find one that is safe and effective. “Honestly, I think the vaccine in 12 to 18 months is a moonshot,” Smith says.
In the meantime, we might be able to find a treatment sooner. The World Health Organization is currently facilitating a multinational clinical trial, testing medicines — and combinations of medicines — to treat Covid-19. If scientists do discover “drugs that decrease the ICU time by 20 to 30 percent, that would add up,” Omer says, and ease the strain on hospitals. But even those drugs wouldn’t necessarily stop the outbreak.
“It would be really great, I think, for saving lives,” Rivers says. “But you wouldn’t really expect it to slow transmission at all.” People could still be getting sick and spreading the virus. And we would need to be vigilant, and patient, in this scenario, too. Even if we reduce the risk of severe disease and death, if we increase the number of cases, more people can still get sick and die.
This is the time to prepare — and to get it right
The scientists I spoke to for this piece all understand the extreme weight and burden of social distancing. “The economic concerns have real impact on health,” Omer says. “It’s not that we’re being cavalier about this stuff.” The economic ramifications of the pandemic are only adding to existing mental health strain. The scientists want it to end too.
But a balance is needed. “I don’t want to turn the economy back on in a way that just nukes our hospital system, and that’s what we would do right now” if we abruptly ended social distancing, Konyndyk says.
So whatever time we buy with social distancing we need to use wisely. We need to ramp up production of critical hospital supplies; we need to establish supply chains for the massive testing regime that will be needed. We need to train more people to help. And we can do this. “Amazon was born in this country, UPS was created in this country, and we are teaching supply chain logistics in every management school, and we can’t have a stable supply chain of personal protective equipment?” Omer says. Clearly, we can — and need to — do better.
But all this requires leadership. President Trump has been hesitant to use the full power of his office to make sure companies produce the needed supplies. If anything, he frequently uses his office to downplay the harms of the virus and hawk unproven cures.
Right now, we still have a chance to reduce the amount of harm this virus could cause. How? “Let’s figure out testing, let’s get enough PPE [personal protective equipment] for first responders,” Smith says. “Let’s get enough swabs. Let’s buy more ventilators, build more ventilators — to have this second chance at not messing things up.”
We need to do this as a nation. While the pandemic is now hitting the New York region the hardest, it will in time likely hit other cities hard as well.
The greatest power we have right now is patience. It’s not easy to muster in the face of such sacrifice. And at times, it can feel ineffective. But where you find it, drink it in. Currently, it’s likely our best chance at a cure.
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