What now? More questions than answers
After more than a month of the national lockdown aimed at stemming the spread of COVID-19, plans for how the United States can move back toward normalcy have begun to emerge. The centerpiece of discussion has been the extent to which the country is able to massively ramp up accurate testing for the virus — a point of contention between the White House and leaders in the most heavily affected states since the outbreak’s earliest days.
Vastly different emotions and concerns underlie the urgency and favored approach to reopening, largely guided by geography and personal experience.
In recent weeks, grassroots protests to “liberate” various regions gained wide attention after some were encouraged by President Donald Trump. At the same time, a set of governors from southern states have created a coalition aimed at speeding up the reopening of their economies. Last week, Georgia Governor Brian Kemp’s plans to allow several non-essential businesses and institutions to open under restrictive guidelines elicited controversy and even sharp disapproval from the president, who has generally favored approaches to accelerate such efforts.
For those in the New York metropolitan area and other hard-hit regions, financial hardships, cabin fever, and an anxiousness to return to life as usual are soberly tempered by fears of what loosening the reins might bring. For the Orthodox community and others in areas with high rates of infection, the recent high toll in lives and ongoing suffering continue to overwhelm such desires — and the prospect of emerging from our homes only to deal with another round of unmitigated illness is a frightening one. More than two weeks ago, a team of governors from the Northeast joined forces to discuss plans for a coordinated reopening, but all still say that significant steps in that direction are not yet on the horizon. Irrespective of the details of what plans public officials might pursue, it is difficult for many, who feel they have been kept safe from the virus through social isolation, to imagine a safe way to creep back to regular interactions, and wonder if one really exists short of a vaccine or effective treatment.
Testing, Testing, 1-2-3
Two weeks ago, the White House unveiled a three-phase plan: “Opening Up America Again.” Phase one encourages maximum social distancing to continue but says that employers should seek ways to gradually resume their businesses, and it lifts restrictions on the healthcare system like the cancellation of elective surgeries. Phase two tells the elderly and others with underlying health conditions to continue to remain isolated, and urges the avoidance of crowds larger than 50 people, but allows venues such as restaurants and houses of worship to operate under “moderate physical distancing protocols.” Phase three would see most Americans return to their workplaces and daily routines, with minimum warnings to avoid time spent among exceptionally large crowds. The first phase is predicated on states seeing a downward trajectory of new cases and the second two are based on states not showing any signs of a rebound in infection rate.
A prerequisite to launching the White House’s plan, or most others that have been proposed, is the ability to conduct widespread testing and obtain accurate data about the direction of statistics on the virus and then identify infected individuals, as well as those who might have at least short-term immunity to COVID-19. Expanding testing beyond the sick and hospitalized is also essential to containment, as researchers increasingly believe that a high level of spread has been caused by people who are asymptomatic.
The facts on testing availability and whose responsibility it is to provide it have been a consistent sticking point.
Nearly a month ago, when tests were limited even for symptomatic individuals and off-limits to healthy ones, the president claimed at a press conference that “anybody that wants a test can get a test.” In subsequent statements and conversations with local officials, he acknowledged limited supplies and worked on strategies to address this, but he has wavered on the need to prioritize testing capacity.
The situation on the ground has been slow to change. In hard-hit New Jersey, two mass-testing sites supported by the federal government have been in operation for nearly a month, but only for people exhibiting symptoms, and many smaller venues will only test those deemed high-risk. As recently as last week, the state’s governor, Phil Murphy, said that availability was still not broad enough to allow for screening of asymptomatic individuals.
As the administration’s plan was rolled out, Vice President Mike Pence, who leads the White House’s coronavirus task force, said that testing capacities would soon be in place to begin phase one in applicable areas of the country.
The vice president and federal health officials say that 120,000 people are now being tested nationally per day.
As of last week, a total of about 4 million COVID-19 tests had been administered in the U.S., half the rate as that of Germany, Italy and Spain.
The administration drew criticism from several governors in the Northeast for its plan to pass the buck on testing to states, saying that there was no way to reach the necessary capacity without significant federal funding. The most recent stimulus package allots $25 billion to states and laboratories to increase testing, but whether that will fit the bill remains unknown.
“I don’t think money is the main issue here,” said Awi Federgruen, an expert in statistical analysis and applied sciences and a professor at Columbia University. “The government is spending trillions in aid packages — and rightly so — to help small businesses and hospitals, but the supply-chain issues involved in producing testing materials make me pessimistic that they can get this done on the level that they need to. We’ve seen bottlenecks even for swab materials, which are not being produced at nearly the numbers they should be. We are seeing movement now, but it’s not at a fast-enough pace.”
Congressional Democrats had criticized the White House for its reluctance to use the Defense Production Act to increase output of testing materials. Last week, though, officials seemed poised to invoke the wartime law, which allows the federal government to order private industry to produce certain goods on demand at a given price. Trump administration advisor Peter Navarro announced that Puritan Medical Products had been ordered to increase output of swabs from 3 million to 30 million per month in 30 days.
Doug Badger, senior fellow at the Galen Institute, a health care policy think tank, and former advisor to the George W. Bush administration, said that the ongoing lack of clarity might have played a significant role in the White House’s hesitancy to use the Defense Production Act.
“We still don’t know the reliability of a lot of these tests,” he said. “The Defense Production Act is a blunt instrument, where the government comes in and says what to produce. If you’re not sure what will work in the end, you could get stuck with warehouses of tests that will never get used.”
Even as testing materials become more available, laboratories that can process and analyze results remain in short supply. A New York Times article traced a nasal swab’s journey under the title, “3 Vans, 6 Coolers, a Plane, a Storm and 2 Labs.” Mr. Badger said it was unclear if the stimulus money would help address the issue.
“Testing manufactures are rising to meet demand, but the labs are not keeping pace,” he said. “The political deal that was cut will give some money to states and some to laboratories, but we will have to see if it is allocated properly and that means increasing lab capacity, since no matter what strategy to reopen you want to take, they will all need a lot of testing.”
While most tests administered to people exhibiting COVID-19 symptoms are believed to be reasonably accurate, screening for antibodies to show whether one had the virus and likely developed some level of immunity have had mixed results. While those designed specifically to detect IgG, the antibody produced by COVID-19, have been shown to be largely accurate, many cheaper and more-widely-available tests being given to the public are less reliable.
Especially as researchers presented findings that many people could have had COVID-19 without ever experiencing symptoms, the tests are seen as an essential step in moving any region toward a safe reopening strategy. Such data could help identify those at lower risk of contracting the illness and provide policymakers with the numbers they need to determine the level of viral spread that could make reopening efforts a reasonable move.
As of late last week, New York City’s tally of positive cases stood at 142,000, but Department of Health and Mental Hygiene commissioner Dr. Oxiris Barbot admitted that the figure was “the tip of the iceberg,” guessing that the real number of those infected could likely be closer to 1 million.
Many of the new tests that have reached the market are a result of the FDA’s lowering of standards in an effort to gather more information about the epidemic. Professor Federgruen said that as long as it is understood that results are less accurate than they would be under normal circumstances, the FDA had made a “good move.”
“The higher percentages of false positive and false negative results adds another layer of complexity, but a lot of testing is the only way to gather the data and begin to really evaluate the situation; it’s better than flying completely blind, which is what we are doing now,” he said. “Every pandemic has a shape and peak and then goes down. The question that we need an answer to is, where are we now?”
A Way Forward?
Given the remaining limitations of mass testing, some strategists have looked for ways to maximize what resources can be made available and move forward.
While insisting that large-scale testing is a necessity, a plan mapped out by Yale Public Health Professors Edward Kaplan and Howard Forman in an opinion piece in USA Today suggested focusing resources on areas known to be at higher risk, such as densely populated housing projects and nursing homes, rather than using kits for random samplings.
“You could get away with doing less testing by focusing on hard-hit areas. You don’t need to spend as much time on the leafy suburbs as you do on the Bronx,” Professor Kaplan told Hamodia. “New places to look for infections will pop up, and so this plan would have to be agile and have quick and easy rules that would allow for shifts.”
Professor Kaplan admitted that even such an approach would be a daunting task in areas such as New York City, where he said testing would have to be raised to 100,000 to 200,000 per day before a safe reopening would be possible. Still, he felt that drafting a broad team to help in the effort could make it possible.
“You will need healthcare workers at some level, but not for all of it, so you could think more creatively and do things like getting the fire department involved,” he said.
As incidence decreases, finding and isolating infected individuals will take center stage in containment efforts, and for that to occur, Professor Kaplan said, government will also have to come with workable options for quarantining individuals who cannot safely do this at home.
An article by Mr. Badger and Galen Institute’s President, Grace-Marie Turner, published in Real Clear Health, said that private industry held more capacity to ramp up testing than government-run efforts and suggested that the lion’s share of the $25 billion be focused on lab capacity.
Mr. Badger said that the U.S. could not undo its late start on testing, but did not feel that this should stand in the way of regional reopenings, beginning with areas that have seen a very low incidence of cases.
“We’re in a better place on testing than we were a month ago or even a week ago, but I still don’t think that it’s feasible to wait for testing to be universally available to start looking to open up some areas,” he said. “Our recommendation is to consider opening up regionally and look at factors like infection rates and density. … Most areas of the U.S. have still seen very slight effects so far from COVID-19, but we’ve essentially asked 300 million people to treat themselves as if they have been infected and to lock themselves up. It makes sense for high-incidence areas like New York City, but if we keep the whole country’s economy locked down, we could be causing more harm than good.”
Besides the damage being caused by widespread unemployment, a freeze on much of the nation’s economic activity and an unprecedented level of debt spending by the federal government, Mr. Badger worried that unilateral moves to free up hospital space, such as cancellation of elective surgeries, could backfire.
“Ninety percent of COVID-19 deaths are associated with co-morbidities; idling hospital capacity at the expense of necessary care in areas where there have not been large outbreaks puts the most vulnerable patients at higher risk by not treating the conditions they have now,” he said.
New York’s Governor Andrew Cuomo had resisted the idea of opening largely unaffected upstate regions while the metropolitan area remains the epicenter of the nation’s outbreak, fearing the ill effects of migrations by infected individuals to cold zones of the state. Yet, a day later, he retreated from this approach and said that areas such as Western New York, Buffalo, Rochester and the Finger Lakes region would begin to open, starting with the rescheduling of elective surgeries in hospitals that do not have significant COVID-19 patient loads.
Mr. Badger said that for a regional reopening plan to work, a controversial implementation of travel restrictions on citizens from highly affected areas would be a helpful tool in protecting regions ready to begin a return to normalcy. He pointed to South Korea’s internationally touted success, which, in addition to implementation of universal testing, utilized self-containment orders to affected regions and strict quarantine policies.
Several experts looking at reopening plans have criticized a lack of national strategy, saying that too much discretion has been left to local officials. Professor Federgruen agreed with this assessment but said the need for central direction need not stand in the way of regional openings.
“It has to be coordinated, but it does not have to be uniform,” he said. “It should take into account the level of movement between different locations and other such factors; it doesn’t have to be one size fits all. At the same time you don’t want local officials making decisions in a bubble, which is what seems to be happening in some places now.”
All plans for reopening are predicated on the ability to conduct testing on a level that will allow authorities to identify the vast majority of infected individuals and then to quarantine them and their contacts before they are able to spread infection to a wider circle of people. The strategy was used briefly early in New York’s outbreak, when Lawrence Garbuz, the lawyer from New Rochelle, was diagnosed, setting off a quick chain reaction that shuttered his hometown, Yeshiva University, and several Jewish day schools. The approach only worked for a limited time, as community spread quickly made COVID-19 a borderless problem, essentially placing the entire country in the same quarantine as New Rochelle.
If social distancing practices yield a sustained downward spiral of cases, the hope to slowly open businesses while employing an army of “disease detectives” to trace and isolate infected individuals and those they have been exposed to would be the next step. Given the size of the city and the speed with which such an approach spiraled out of control in early March, some have met the suggestion with skepticism.
Yet, many have pointed to South Korea’s — and more recently, Israel’s — effective employment of such methods as proof that they are indeed feasible.
“South Korea has been using an app to trace people, and it seems to have worked,” said Mr. Badger. “There is technology available to make this much easier, and today you shouldn’t need thousands of new medical workers to make it work.”
Professor Kaplan said that increased ability to do contact tracing is the only effective strategy to safely allow for society to return to functionality until a vaccine or effective treatment for COVID-19 can be developed.
“You have to test, test, test — and find the infected people that are out there,” he said. “You need to do this in a very aggressive way, and I think it’s important for states to show that they can get this started now. If you look at Israel, they went to a real extreme, sent out the police and found 500 infected people with no symptoms and locked them up, but now they seem to be on the way out of their outbreak.”
Not So Fast
Even in the event that the downward trend of infection numbers continues and tracing methods are effectively implemented, experts say that the day Americans are waiting for, when a bell rings that life can go back to the way it was, is unlikely to be what a “reopening” will look like. Rather, what is envisioned is a staggered attempt to revive the economy, while social distancing continues as a means of fending off a viral rebound.
“If you open up too soon we will get a rebound. All the models agree that is what will happen, and it makes sense, since we got to where we are now by keeping everyone at home,” said Professor Kaplan. “We don’t want to just let people go back to what they were doing before, and we have to do it in a smart way that allows businesses to reopen but that encourages them to reimagine their process.”
Such an approach encourages businesses to allow as many employees to work remotely as possible and for other societal gatherings to continue only if social distancing is practical. The moves could significantly change the way that Jewish life would be ideally envisioned by public health experts during such a period. A recent study by Johns Hopkins University that offered advice to governors on a phased reopening listed houses of worship, schools, camps, and large gatherings such as weddings and funerals with many attendees as presenting the highest risks, and which needed the most modifications.
“It could very well be that shuls and weddings will take longer to open or return to normal, which is painful, but I would assume that government’s priorities will be education and employment,” said Professor Federgruen. “My guess is that what we will see in New York is a gradual return that could take various forms. It could be that schools will start with staggered classes that will allow for half a class to be with a teacher at a time. Companies could also be asked to stagger if they can; if we then see no significant increase in infections, we can progress from there.”