The Next Big Test: Re-opening our Society and Economy

Over the past week, the media has been reporting that federal and state officials have been working with public health experts to determine how to safely begin the re-opening of our stay-at-home society and economy. The challenge is to do so in ways that will not lead to a second major wave of COVID-19 infections and deaths. 

Literally all public health experts and the governors of most states agree that any relaxation of stay-at-home orders must be gradual and focused on those businesses and individual activities most capable of maintaining the imperative practices of physical distancing and thorough hygiene, as well as appropriate mask-wearing. Here in Vermont, the Governor has announced the first of what are sure to be a series of gradual relaxations of our stay-at-home orders.

Meanwhile, in some states COVID-19 related “stay at home” orders have not yet even been issued, while in others they are becoming increasingly politicized in the shadow of the coming November elections.
The enormous challenge posed by relaxation of stay-at-home orders is for state and large-city public health systems to this time be ready and able to respond and control outbreaks of COVID-19 that may re-emerge. In order to do so, public health and other government experts warn that at least the following conditions and capabilities must exist at the state and large-city levels:
  • Hospitals and other healthcare facilities must have the capacity and equipment necessary to protect their front-line staff and to treat all their patients, those with COVID-19 symptoms and those with other medical needs.
  • State and large-city health departments must have in place a robust system of testing, contact tracing, and quarantine/isolation. 
  • There must be a state and/or city-wide sustained reduction in cases for at least 14 days.
Moreover, the success of re-opening a state or large city's stay-at-home society will depend to a large extent on its citizens' willingness to: voluntarily participate in a system of testing, contact tracing, and quarantine/isolation; follow public health guidelines regarding physical distancing, hygiene, and mask-wearing; and cooperate with any government emergency orders that may become necessary.

Let's briefly look at what may be required to attain the above conditions and capabilities and what may be some of the obstacles to doing so.


Hospitals and other Healthcare Facilities
The relatively good news is that, probably as the result of stay-at-home orders, to date most hospitals have not been completely overwhelmed. However, many healthcare facilities have paid a heavy price in first-line staff illnesses and fatalities, especially hospitals in high density, low-income neighborhoods, as well as nursing homes serving particularly vulnerable populations. 


Moreover, it is uncertain if these healthcare institutions have the capacity or financial stability to withstand a second wave of COVID-19 cases, particularly if a relaxation of stay-at-home orders in combination with increased testing lead to a large surge of cases. For example, as of April 2, Vermont had too few ICU beds and ventilators to meet even the most optimistic scenario, which envisioned us still under stay-home-orders through mid-May. It has nowhere near enough such equipment for a larger surge that could occur when stay-at-home is relaxed. Nor is it clear that Vermont healthcare systems would be able to acquire needed equipment if competition among cities, states, countries, and even our own federal government for these vital resources continues to be a challenge affecting availability and cost.


A Robust System of Testing, Contact Tracing, & Quarantine/Isolation 
In order to stop the spread of any infectious disease, public health systems must be able to identify those who are infected and then identify and contact others whom they may have infected

Then, those who are believed to have been exposed to the disease, but do not show any symptoms, would need to self-quarantine at home under careful self-observation and/or observation by others in their households and to contact a health provider should any possible symptoms arise. 
However, for a robust system to stop the spread of a “novel” virus like COVID-19--- for which the population has no immunity and there is as yet no vaccine or proven pharmaceutical treatment---those who test positive must be isolated, whether at home or in an isolation facility or at a hospital if symptoms are serious enough to require it.


That’s how such a system should work, but here are some of the known obstacles:

1. Testing:
States must be able to test many more people in many more situations, not just those who present serious symptoms and/or essential workers who are most likely to become infected or “people with connections.” They need to test people who may be totally asymptomatic or show very slight symptoms themselves, but might infect others, especially those at higher-risk. They need to test people who may not have personal care providers-- those who live in sparsely populated areas like the Northeast Kingdom of Vermont or people who are homeless or incarcerated. And they may need to test essential front-line workers more than once since they might easily become infected after previously testing negative.

However, to date, no state seems to have adequate test kits and/or the capacity to process them and return reliable results in a timely manner. As of April 19, the CDC reported that a total of around 373,000 tests had been processed nationwide; i.e., approximately .1% of the number of people currently living in the United States.

Of course, these are nationwide statistics and, it’s clear that some states have been able to source and have processed more than their “fair share” of tests; however, even these more fortunate states are highly unlikely to have the capacity for the levels of testing that would be needed for a robust system of testing, tracing, and quarantine/isolation. For example, as of 4/19/20, the Vermont Department of Health reported that since testing began in earnest about 6 weeks ago,12,726 tests had been “completed,” which is roughly 2% of people residing in our state; i.e. well above the national average of tests “processed” but far from enough for a robust system that would identify significant numbers of carriers. 


2. Contact Tracing
Contact tracing involves identifying, locating, and informing anyone with whom someone confirmed as being infected has had contact within a certain period of time. Such an approach has never been attempted in the United States at the scale that would be needed to make a dent in the rate at which COVID-19 has spread and could continue to spread, especially if stay-at-home orders are abruptly relaxed or ignored.

There has been talk of using U.S. Census teams to carry out some door-to-door contact tracing, but to date, Massachusetts seems to be the only state to begin actually attempting contact tracing on a large scale.  In creating their plan, Massachusetts officials have been drawing upon the experiences of such large scale efforts in asian countries that were slammed by MERS and SARS in recent years; and it seems likely that Vermont and other neighboring states will be keeping a close eye on their experiment, in terms of both its effectiveness and cost.

The potential for such an approach to work in a small rural state like Vermont seems like it could be a mixed bag: on one hand, we have many fewer people to reach; on the other hand, it may be difficult to reach people in sparsely populated areas, and then there’s the always present political issue of the cost to the state and its taxpayers. 


3. Quarantine & Isolation 
This is where we begin to wade into the tricky territory of personal freedoms and state mandated behavior. Once people test positive for COVID-19, to what extent can or should the government determine what they or anyone identified as having had contact with them should or shouldn’t do? Or, to put it in another way: in the midst of a public health emergency like COVID-19, where is the line between a government recommendation and a government requirement?

“Barr: Some governors' action 'infringes on a fundamental right' during coronavirus,” The Hill, 4/21/20

The media is already carrying stories about angry public protests against stay-at-home orders in Michigan and elsewhere, which does not bode well for government-mandated quarantine or isolation. Fortunately for us in Vermont, our Governor seems to have confidence in Vermonters’ capacity for self-regulation, a good sense of when and how restrictive an executive order needs to be, a light touch when it comes to enforcement, and skillful communication of all of these. (Note: this is not meant as a political endorsement, but rather a fair assessment of his leadership and performance during this crisis, so far.)


Nevertheless, Governor Scott and Vermont public health officials are going to have some tough calls to make, as they relax components of Vermont’s various stay-at-home executive orders and as more testing is done, which will almost certainly uncover more people who are infected despite having few if any symptoms. Among these decisions is almost certain to be whether or not to mandate home quarantine for people who are known to have had contact with someone who tested positive and/or isolation for those who test positive; or to leave these choices up to them. 

For example, contrast Vermont’s current recommendation regarding masks with New York State’s mandate to do so:

4. A sustained reduction in cases over a period of 14 days
The epidemiological reasoning for why this should be a requirement for the safe re-opening of a state or city is too complex to explain here, except to say that it is based on the idea that it can take up to 14 days for infected people to show symptoms. 

The most serious difficulty with this requirement to have a "sustained reduction in cases over 14-days" is that without mass testing, we simply have no meaningful way of counting cases. Consider the following:
  • To date, the number of people who have been tested nationally and in most states and cities is a very small and gradually increasing target, so that it is almost impossible to make any kind of statistically valid projection of numbers of people infected in the overall population of a state or municipality.
  • In the absence mass testing the number of cases being counted will continue to leave out most of the many carriers who are asymptomatic or who may have very mild symptoms, even though they are, in fact, the most likely spreaders of the disease. 
  • Largely due to the need to ration limited test kits and processing capacity, the criteria for ordering tests to be done varies widely among cities and states and even within states, resulting in unknowable variations in who is and isn't counted as a case. For example, some “pools” of testing data may consist mainly of people in “hot clusters” (like nursing homes or correctional facilities) or essential workers with high exposure (like healthcare workers) while other “pools” might consist of people with few if any symptoms (like players and staff of sports teams or others “with connections”).
A smaller, but absurd factor, in making case counts hard to take seriously as a criteria for re-opening is the fact that some states and cities haven’t been counting as “cases” many people who have died as a result of COVID-19 without ever having been tested. (This is the main reason that we have seen huge one day jumps in mortality statistics when states or cities decide to count such deaths as COVID-related after not having done so initially.)  

There are other measures that have been proposed to signal when it might be safe to re-open, but all of these have the same basic flaws: too few tests and almost no random sampling or advanced statistical treatment of the data that we do have, without which we don’t have statistically reliable infection data on any of a wide range of sub-populations (e.g., by age, gender, race, geography, occupation, housing situation, etc.). 

As a result, for example, we have no way of measuring rates of infection, severity of infection, or mortality among people in front-line jobs (particularly healthcare) or in various age cohorts, or living in public housing complexes or prisons, or people with any number of suspected underlying health conditions, etc. Nor, do we have data to help us determine for example, how well ventilators, or various kinds of PPE for health-workers, or hospital hygiene techniques, or various isolation measures are really working to contain the disease.

Indeed, the paucity of testing overall and the non-controlled variation in the sub-populations being tested in the various states and cities, makes the "numbers" being reported to the public by the CDC and health departments nearly useless "factoids."
And to make matters even more confusing, the reporting and interpretation of rates of infection, and mortality are becoming politicized, as government officials at the federal and state levels begin to look at how and when to begin relaxing social-distancing policies in order to re-start the economy.

So, readers are advised to be wary of any person, organization, or media source that makes claims, based on such incomplete and statistically limited data. 


The Road to Semi-normal
As we in Vermont venture gradually into a relaxation of stay-at-home orders, it is important that we recognize not only the obstacles described above, but also the monumental cost of the COVID-19 crisis in financial and socio-emotional terms for the country, including nearly every individual person, most small businesses, entire sectors of the national economy and many of its largest businesses, state and local governments, not-for-profit organizations, and so forth. 
Some populations and institutions have been harmed much more than others, likely irreparably; others will recover and prosper as they have before, but all will be facing a very different country and world than before this pandemic. And although, it isn’t at all clear what this world will look like, it seems quite likely that the same populations that have been most vulnerable in the past will continue to be the most vulnerable, perhaps even more so.


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