If the year 2020 is a horror movie, the month of May is the part where the potential victims, trapped in the house by an unseen killer, crack the door open, oh, so slowly.
Can we go outside now?
In the movies, giving the precise coordinates of the killer would ruin the suspense.
In real life, screw suspense. Health officials agree that it will take widespread testing for the COVID-19 virus, both targeted and randomized, to find and isolate the unseen carriers and hot spots and bring society to a semblance of normalcy.
With or without adequate testing, pressure is mounting in Michigan for Gov. Gretchen Whitmer to ease up on the statewide lockdown.
As April comes to a close, health officials are closely watching other countries, and other states, as they crack the door open and relax the restrictions that have brought the economy to a standstill in the past month.
Test and trace
The curve of new infections and the death rate from COVID-19 has begun to flatten in Michigan, but a second outbreak, or series of outbreaks, cannot be ruled out.
Whitmer has hinted at plans for a phased reopening of the state’s economy, but she told CNN that that it could be disastrous to move too fast.
“As tough as this moment is, it would be devastating to have a second wave,” Whitmer said.
The COVID-19 virus has the fiendish ability to infect people without any symptoms, and jump through a cough, a hug or a handshake to a less fortunate host, who could become ill or die.
“The only reason we’re isolating you, me and everybody else is because we might be infected,” MSU epidemiologist Nigel Paneth said. “If we both know that neither of us have an active infection in our nasal pharynx, we can hang out together just fine.”
Ingham County Health Officer Linda Vail said broad-based testing is critical to cracking the state’s doors.
“Testing level is one of our keys to being able to reopen,” Vail said Friday. “We have to be able to test, and test in large numbers. If we can’t, we can’t isolate those who are sick and identify those who were exposed to the sick. We cannot get through this without the ability to do that.”
But Vail didn’t offer any specifics on the state’s testing capacity.
“We’re making a lot of progress,” she said. “I don’t have a lot of numbers on exactly what our massive testing capacity is right now in the state, but what I do see is this consistent influx of more testing capacity.”
However, the United States has been fatally behind on testing from the very start of the pandemic, and Paneth is at a loss to explain it.
“There are close to 40 approved test kits approved by the FDA,” Paneth said. “The question is, how can we ramp up production, distribute it and get it to the people that need it?
The Trump administration has engaged in a tug of war with several governors, including Whitmer, over the availability of testing equipment.
On Sunday’s “Meet the Press,” Whitmer said the state could perform “double or triple” the number of tests it is now conducting “if it had more swabs or reagents.”
“This is what America’s famous for — the ability to produce, supply, distribute,” Paneth said. That’s why our supermarket shelves look better than anybody else’s. It’s a simple cotton swab with a little bit of a PCR (polymerase chain reaction) material on it. The thing is not that complex.”
On top of supplies, hundreds or even thousands of temporary workers will be needed to conduct widespread testing. Paneth proposed to MSU that all of its medical and nursing students be mobilized, for a three-month public health credit, to test the entire state.
“Most of them are home right now,” he said. “Deputize them as part of the public health department. They go door to door and test every single person for COVID-19,” Paneth said. “If you’re positive, you’re quarantined, with a sign on the door, like we used to do with diphtheria and smallpox.”
Two rounds of testing, Paneth said, would enable a return to near normal activity across the state.
“Everybody who has tested negative twice — and that’s almost everybody — and is not in a high-risk activity, can resume activity,” he said. “There would still be some restrictions, but businesses, shopping could open up.”
Many health experts insist that in addition to testing, aggressive contact tracing will be needed to locate infections and hot spots.
In Massachusetts, Gov. Charlie Baker announced a partnership with Partners in Health, a Boston-based nonprofit, to recruit and train 1,000 people to do contact tracing of everyone who tests positive. Utah, North Dakota and other states are in various stages of planning a similar program
The tracers call infected people, ask them with whom they’ve been in close contact within the past two weeks, and then call those people to alert them that they may have been exposed. (“Close contact” is usually defined as being within six feet of someone for more than 15 minutes.)
Callers don’t reveal the name of the infected person, although it is not hard for people to infer who it is.
Ideally, everyone who gets a call is tested, but no states have that capacity. Under the Minnesota program, people who have been in close contact with an infected person will be asked to self-quarantine for 14 days, thought to be the maximum incubation period for the coronavirus. Baker said the tracing program will cost $44 million.
Some public health leaders say it’s too late in the pandemic, at least in the hardest hit areas, for contact tracing to be workable and effective.
But Robert Redfield, director of the Centers for Disease Control and Prevention, told NPR last week that “very aggressive” contact tracing would be necessary before the country could go back to normal.
Contact tracing is labor intensive and better suited to communities with a moderate number of infections. An all-out program in Germany made headlines this week.
“This would be doable in Ingham County,” Paneth said. “New York City is another story. It would make it possible for some communities to open up a little bit.”
At Tuesday’s coronavirus briefing, Vail said testing capacity in Michigan “unfortunately differs across the state.”
Capacity for contact tracing, Vail said, is “lower than we’d like to see it right now. All of the thing are in place to increase it, but we would have liked to have seen it increased before we started talking about reopening.”
‘You think you’re safe’
Doors are beginning to slowly crack open across the country and around the world.
In Germany, where the rate of infection has been slowing and hospitals are not overwhelmed, shops smaller than 8,600 square feet reopened Monday for the first time in a month, with customers required to maintain a five-foot distance from each other. Car dealerships, bike shops and bookstores of any size were allowed to reopen. Some German states have allowed zoos to open. All large gatherings are still banned through the summer.
Germany, Iceland and South Korea have begun massive testing programs to learn who may have been infected, where hot spots are and what further restrictions need to be put into place. Over 100,000 people a day are being tested in Germany, and Chancellor Angela Merkel said the goal is to trace “every infection chain,” The New York Times reported Saturday.
In Italy, one of the hardest-hit nations in the world, Prime Minister Giuseppe Conti said lockdown measures would be cautiously eased May 4.
However, Hong Kong and Singapore stand out as cautionary tales against opening up too soon. Despite a marked success in containing infections in both Far Eastern city-states, the virus roared back after restrictions were loosened.
In the United States, governors differ on how and when to reopen. Gov. Mike DeWine of Ohio said he expects some of his state’s restrictions to be lifted May 1.
California Gov. Gavin Newsom specified six conditions that need to be met before lifting shelter-at-home restrictions:
- Widespread testing and contact tracing.
- Capacity to care for older and more vulnerable citizens after reopening.
- Hospital capacity to handle a surge in cases while resuming full non-virus patient care.
- “Identification of promising treatments.”
- Drawing up new guidelines for social distancing in businesses and schools.
- Working out an early-warning system if stay-at-home orders need to be reinstated.
Without a federal mobilization to make testing and monitoring widely available coast to coast, reopening in the United States is likely to be a patchwork of fits and starts.
Restrictions are being lifted most swiftly in the South.
Many retail stores opened Monday in South Carolina. Tennessee’s Gov. Bill Lee said his state’s stay-at-home order would expire at the end of the month.
In Georgia, Gov. Brian Kemp said Monday he would allow many businesses to reopen Friday, including gyms, barber shops, tattoo shops and bowling alleys, but with social distancing restrictions. Theaters and dine-in restaurants would be allowed to reopen Monday.
“If we have an instance where a community starts becoming a hot spot, I will take further action,” Kemp said.
When health officials expressed fears that the reopening would lead to more infections, Atlanta Mayor Keisha Lance Bottoms agreed and urged citizens to stay at home anyway.
Vail called the reopening in Georgia “premature, in the midst of an upswing in cases.”
“Hopefully, we don’t make the same mistake here,” she said.
Vail suggested that reopening Michigan would look, at first, much like the early stages of the state shutdown, beginning in March, only in reverse.
“First we cut capacity in bars and restaurants by 50 percent before the larger closures,” Vail said.
She said the restrictions most likely to be lifted first are “low-risk” activities such as golfing and fishing.
Sports, bars, concerts, festivals and anything else that “packs people in” will likely be “on the far end” of the strategy, Vail said.
Vail divided the state’s pandemic response into three phases: the all-out “suppression” phase currently underway; the “containment and mitigation” phase that will come next; and the endgame of “herd immunity” or a vaccine.
She said many policies that are now in place now should continue indefinitely, well past the current suppression phase — screening of all essential employees, social distancing, and maximizing telecommuting, restricting or banning large gatherings.
Containing the virus during the delicate dance of reopening depends, in large part, on whether enough people continue to practice distancing and other precautions.
“Asian societies have done a good job,” Paneth said. “People there are more ready to take a community-based approach — the very opposite of those protesters in Lansing the other day.”
While millions of people, in Michigan and around the world, have endured unprecedented restrictions to save lives and protect overburdened hospitals, the protesters in Lansing, and around the country, see the lockdown very differently.
“They think it’s all about the rights of the individual,” Paneth said. “It’s no different from showing them gun-related mortality. It’s not about communal numbers. It’s about me, my individual thing.”
John Goddeeris, an economist at MSU who specializes in the interplay between health care and the economy, said it’s not enough to count on self-interest to expect people to abide by social distancing and other restrictions.
He invoked the classic economic concept of “externalities” — the costs of harmful practices by people or corporations that fall on others, at no cost to the person who caused the harm.
The term is most often used to describe ecological damage and sickness caused by mercury pollution from power plants or carbon dioxide from auto emissions, but it’s just as apt for a person who transmits the coronavirus without succumbing to COVID-19.
“We want people to wear masks, not only to protect themselves but also to keep them from infecting other people,” Goddeeris said. “That’s not just self-interest. You have to be aware of the effect you might be having on other people. A lot of people do that with social distancing, but I’m not sure everybody will, and it only takes a few to cause a real problem.”
Living in a sparsely populated or remote area, Paneth said, does not afford as much protection as many people think.
“You think you’re safe because you don’t have the agent where you are,” Paneth said, referring to the virus. “It’s a fantasy. Bring the agent in. That’s all that’s lacking. You’ll find out quickly how easy it is to spread.”
Paneth recently got an email asking why a sparsely populated state like Utah couldn’t reopen, in view of the relatively few COVID-19 cases there.
“As soon as you get the agent into Utah it’ll burn through Utah just like it burns through everybody else,” he said.
Hammer and the dance
Two weeks ago, before angry protesters and presidential tweets dragged the question of reopening the economy into the political arena, governors and health officials weren’t the only ones who were urging caution.
President Donald Trump got a strong message on the need for more widespread virus testing from leaders of the retail, hospitality, banking and financial sectors of his task force on reopening the economy, according to The Wall Street Journal.
The task force members told Trump that it would be difficult to reopen the economy until the public felt safe enough to return to work, eat at restaurants or shop in stores, and the only way to restore confidence would be to implement widespread testing and tracking of infections.
A second outbreak could only be the prelude to longer-term economic damage, according to MSU economist Lisa Cook. Cook, a former adviser to President Barack Obama, helped the International Monetary Fund rebuild the economy of Rwanda after the 1995 genocide.
“I agree with the epidemiologists,” Cook said. “This is a health crisis first. If we get the economy back up and running, if we get people back into barber shops, McDonald’s and Starbucks and have them get sick, they’ll never want to go back. It’s tainted. They’ll say, those places put me in danger.”
Cook is closely watching as the doors crack open around the world.
“See what happens when China, Italy, Germany, Australia slowly open things,” she said. “We’re going to have to monitor the rest of the world. It’s going to take time and we’re going to have to have patience.”
There’s another way a hasty reopening could backfire. The executives also told Trump they feared a devastating wave of lawsuits if workers got sick upon their return.
David M. Soloman, the CEO of Goldman Sachs, told The New York Times that after talking with about 100 CEOs who are Goldman clients, he concluded that “unless people feel safe and secure and confident around the virus, the economic impact will continue in some way, shape or form.”
A recent Ipsos poll found that 70 percent of Americans view going to the grocery store as a highly or moderately risky activity, and 57 percent of Americans still working outside the home feel that doing their job is a moderate or large risk to their health.
That’s not a formula for business as usual.
For the time being, the horror movie cycle is the most likely scenario. The potential victims venture out of the house, the killer pops up out of the bushes, everybody goes back into the house until they go stir-crazy and come back out, the killer pops up again, and so on.
An influential March 19 article by Tomas Pueyo, “Coronavirus: The Hammer and The Dance,” laid out a more nuanced and scientific scenario.
Pueyo predicted two recurring phases of life with the corononavirus. Drastic lockdowns — “the hammer” — will be followed by phased reopenings, safeguarded by social distancing measures — “the dance.” Factories and schools might open, along with some stores and restaurants. But even with social distancing and a ban on big crowds, there might be surges of the virus, leading to another round of lockdowns, reopenings and so on, until there is either herd immunity or a vaccine.
If a country is very good at “the dance” and deploys widespread testing, contact tracing, social distancing and travel restrictions to keep the infection rate low, “the hammer” might not have to come down again. Life might even look close to normal until a vaccine is developed.
However, Goddeeris foresees a lengthy period, even after the doors crack open, when people will have to wear masks, stay well apart and forsake potential “super-spreader” events like weddings, funerals and parties.
“One of the things that would concern me is that when we do start to open up, are people going to abide by these things?” Goddeeris asked. “If we start to reopen and do things the way we used to, we could easily get a resurgence.”
It’s a social and medical experiment on an almost unimaginably large scale. How much economic stability, personal liberty and privacy are people willing to trade for reduced risk?
If the risk is high, and the period of danger is short-lived, public cooperation — even with the most sweeping restrictions — is near total, as the world witnessed in March and April.
If the risk is low, and the period of danger stretches out indefinitely, even minor restrictions will likely be a tough sell.
The murky area in the middle, when the risk and the time period are both unknown, is where conflict will be sharpest. In the United States, that’s how late April and early May are playing out, as last week’s Capitol protests demonstrated.
“People need to understand that there are important things we need to do,” Goddeeris said. “Maybe we can reach a kind of a social contract and people can abide by it, but I don’t know if we’re ready yet. You see all these people showing up at the Capitol, and they’re not all that concerned about social distancing.”