It seems that the current thinking in the Trump Administration is to try to relax physical distancing on May 1st and declare victory.
AG Bill Barr, on Fox News, refers to current restrictions as “draconian measures” and says at end of April, he thinks we should “allow people to adapt more than we have, & not just tell people to go home and hide under their bed.”
— Matt Zapotosky (@mattzap) April 9, 2020
That won’t work. The roadmap to re-opening that does not lead to overwhelmed hospitals in two or three weeks after the end of steps that have successfullly flattened the curve involves significant planning and benchmark based actions.
My boss, Dr. Mark McClellan and others have been writing and publishing a series of white papers on what needs to happen as a roadmap to re-open. The overarching strategy is outlined in a March 29, 2020 paper. It splits the pathway into four phases:
Phase 1: Use Physical Distancing and public health measures to flatten the curve and slow the spread.
Phase 2: Gradual state by state or in-state region by in-state region re-opening
Phase 3: Immune protection and return to normality
Phase 4: Prepare for the next pandemic
Right now we are in Phase 1. There are several major requirements of moving from Phase 1 to Phase 2.
Trigger to Move to Phase II. To guard against the risk that large outbreaks or epidemic spread could reignite once we lift our initial efforts to “slow the
spread,” the trigger for a move to Phase II should be when a state reports a sustained reduction in cases for at least 14 days (i.e., one incubation period); and local hospitals are safely able to treat all patients requiring hospitalization without resorting to crisis standards of care4; and the capacity exists in the state to test all people with COVID-19 symptoms, along with state capacity to conduct active monitoring of all confirmed cases and their contacts
This means exponential community spread has to be broken. The reproductive number has to be brought and kept under control and preferably under 1 for several weeks in a state. Part of breaking community transmission is that there must be sufficient testing of high enough specificity and sensitivity widely available in all areas with the ability to rapidly flex testing to regions of high need. We are not close to that yet. We are getting closer to the raw numbers of tests but deployment is still a mess. Another requirement of moving from Phase 1 to Phase 2 is that the hospitals need to be able to withstand local surges from local, contained outbreaks. This means sufficient beds, sufficient ventilators, sufficient staff and sufficient PPE among many other criteria. Again, no state will be there by the end of next week much less the entire country.
Phase 2 requires both massive public health surveillance and the ability and willingness to quickly smother new hot spots of localized infections. This is the test, contact-trace and quarantine model that South Korea has been using. As soon as anyone is suspected of being infected, everyone that they have interacted with is identified and placed into quarantine long enough for an infection to either develop or for a high degree of confidence to emerge that the contacts are not asymptomatic and infectious. This infrastructure will dwarf typical public health capacity as this part of the playbook is really effective when case counts measure in the single or double digits but gets quickly overwhelmed. If Phase 2 steps fail locally, a region or a state can toggle back to Phase 1 to re-break community spread.
Phase 3 is when there is herd immunity through the combination of serological testing to identify individuals who have been infected and recovered and the deployment of an effective vaccine to wide swathes of the population. It is currently unlikely that there is a huge swathe of individuals who have developped immunity to asymptomatic COVID19 at this time.
There is a roadmap to re-open. It is a deliberate set of strategies that allow for triggering actions forwards and backwards as circumstances dictate. It is not a fast process and even as regions move from Phase 1 to Phase 2 or from Phase 2 to Phase 3, significant changes to the social sphere will happen compared to January 1, 2020 expectations.
Moving to a Phase 2 or Phase 3 world on May 1st will dictate that we’re back in a Phase 1 world by Memorial Day as several colleagues have looked at that scenario in North Carolina. The risks of re-opening a week or a month too early versus re-opening a week or a month too late are asymmetrical with far more risk accruing to re-opening and relaxing physical distancing requirements early rather than late.
What could well happen, I think, is that Trump will find/manufacture some metric that lets him declare victory on May 1st and say “everyone back to work”. The Cuomos and Newsoms and Inslees of the country will say “fuck that, we’re listening to actual experts”, but the Kemps and deSantises (deSanti?) will jump at it. And, well, I think we can guess what will happen after that.
Following experts’ advice and taking things slowly and carefully is antithetical to everything Trump and Barr believe and stand for. I consider myself lucky that I live in New York, where the government is mostly sensible and believes in science.
@dmsilev: I agree with all of that.
Governor Inslee of WA sent 400 ventilators back to the Feds so that harder-hit states could use them, which is a hopeful sign for Washington, but I really wish that he did what California did, and sent them straight to NY or NJ or Connecticut. I don’t trust FEMA to do the right thing at all under Trump.
The BBC News reports are pushing stories about other countries starting on the “re-open soon” road. Planning – genuine planning, like you outline above – is one thing. What’s going on with Donnie’s minions is another.
It’s crazy to talk about re-opening “soon” when normal people still can’t even buy toilet paper or PPE. (We managed to snag 50 surgeons masks from China on eBay before the listing sold out (in less than 5 minutes). TP is another thing.)
Even if we’ll “never” have enough testing, the fact that it takes many days to get test results – still – is a huge red flag. A 50-ish colleague at work has been in the hospital with pneumonia. This morning we found out that he tested negative. (Given the reported ~ 30% false negative numbers I’ve seen thrown around, that doesn’t give us great confidence.).
Northam’s order in Virginia is that we’re supposed to be (roughly) locked down until June 10. I assume that isn’t going to change much before the end of April, and maybe not until mid-May (if things go well).
I wish the press would spend less time getting distracted by “OMG we have to get back to work NOW NOW NOW!!!” and spend more time finding out what’s being done to get more PPE, (TP), test kits, testing capacity, treatment, and vaccine and antibody tests out there sooner than later.
The White House will apparently have a tax force dedicated to reopening:
Among the policies being considered:
Cut salaries of public employees and professors
Payroll tax holiday
Tax some non-profits
@dmsilev: Aren’t Georgia and Florida are going to be “on fire” in the second half of April? If hospitals are strained, even evil morons like Kemp and DeStupidest aren’t going to be able to loosen restrictions. I just don’t see how May 1 is any more plausible than Easter was a couple weeks ago.
But this is what I worry about. Actually returning to any semblance of normalcy will require a major national effort, producing tests, coordinating their distribution and usage, collecting and managing data, etc. All things that are simply not going to happen until there is no longer a Republican President.
Even if Dump has a heart attack on the shitter while vomiting out his toxic tweets today and Mike Dense ascends to the Presidency, we still won’t see the kind of national mobilization necessary to actually get this managed.
Such a sensible and clearly-marked roadmap — at least to this non-expert’s eyes.
I am much more schooled in what this country is capable of, and I am afraid we are not capable of following it.
Not for technical reasons but because as a whole, we have the emotional intelligence of a two year old. Or maybe as a nation, we have a serious personality disorder.
Don’t we all know people like that, who have the brains and certain advantages (I guess we are calling that “privilege” these days) and yet can not get their lives together?
This all makes sense and I am glad smart people are modeling scenarios and providing sensible advice. But we all know two things about Trump: 1) he only gives a shit about is his personal and political prospects, 2) he is a short-term thinker. So, I expect maximum chaos.
@Another Scott: Exactly!! Stop listening to Dump mouthing off about “reopening the country”. Ask what what he’s doing TODAY to make that possible!!! He has NOTHING!!
Like that’s EVER stopped them from doing it.
There are going to be 50 different approaches to how to re-open, due to a lack of competent federal leadership. I can’t imagine responsible states will do it in a way that is not very gradual. For instance–no large gatherings, no crowded stores, work-from-home if at all possible, schools remain closed, very limited travel. What could get very interesting are the problems created by travel and commerce, not just between states, but between countries. Everyone is going to want to protect their hard-fought gains, with perceived prejudices.
I’d like to see a lot of the policies put in place to protect the most vulnerable, left in place for now. Such as wearing masks in stores, dedicated shopping hours, limited visitors. Allow them to take furloughs from work without repercussions.
I have confidence in our state government to do this responsibly, I only hope that the federal government won’t enact rules that override them, like happened in Mississippi.
I really appreciate this sensible description of a path back to semi-normalcy… but it highlights the howling void of leadership at so many levels (not just the whitehouse)
What should have been a 6 week crisis with a long tail is going instead to be 12-18 months of cyclical panic.
Mike in NC
How does Bill Fucking Barr pass himself off as a expert on pandemics?, Oh, that’s right, he just needs to suck up to his deranged mob boss. We’re probably going to see thousands of evangelicals defy the real experts and pack themselves into their megachurches this coming Easter Sunday because the Baby Jesus told them to. Then the shit will really hit the fan, especially in the deep south.
@hitless: You know, it’s events like this and responses like that which make me shake my head every time someone tries to say that shock doctrine isn’t a real thing. We’ve already seen politicians capitalize on this outbreak to push through measures that would never fly in normal times. It’s absolutely no surprise whatsoever that they’re also pushing the same Koch-level wishlist they always do now.
And seriously, WTF business does Barr, ostensibly an attorney general only, have here? This is either a health and economics question or, if you’re a raging sociopath who only cares about the markets, an economics question only. What it isn’t? Something an AG has any subject matter expertise on.
For what it is worth, this is the approach being considered in Germany, where there has been a lot of testing a tracing, and there seems to be a growing consensus that grocery stores, for example, have not been a means of contagion. I suspect there may be a lot of standard Germanic social distance behind these results.
As translated by RTL:
@ziggy: Our state (Washington) has already closed schools for the year. I wonder if our orders will extend until June now.
Le Comte de Monte Cristo, fka Edmund Dantes
Art Laffer should be beaten to death with a baseball bat. I volunteer as tribute.
Okay, okay…This all sounds very clear and sensible. BUT!! How about if we…didn’t do the preparation, or the testing, or the controls, or the distancing. I mean, think about how huge the economy could be if we roar back with full employment just one month after the panic button was pushed? That would be great!! And the warm weather will take care of the virus-it doesn’t live in hot places; many people have said that, it’s true.
And honestly, the places hardest hit by this are going to be the big cities, like NYC and LA and Chicago, and they don’t vote Republican anyway, so…
New Deal democrat
This is your helpful reminder that the Federal government is one of limited powers, while the States have plenary, or polis powers. The US Supreme Court already decided one century ago that the States have the right to quarantine, and the Federal government’s power to “regulate interstate commerce” does not supersede it.
So long as the States let commercial traffic through (e.g., trucks and non-passenger trains), Trump has no power to force them to open up.
The Moar You Know
Prediction, as per my ex-girlfriend who used to work for Sandia’s bioterrorism unit where they gamed all this sort of thing out:
May 1, Trump declares “victory” as the 2 trillion dollar handout to his cronies has all been safely distributed. He terminates all Federal coronavirus-related unemployment, health and other benefits. California, NY, VA and WA all gamely try to hang in there with lockdowns, but the unemployed will be reduced to state benefits only. Keep in mind states can’t run deficits, so those benefits won’t last – even CA doesn’t have the money to keep this going more than a few weeks without the fed money. When these states run out of money, those unemployed will literally run out of food. Large-scale violent rioting will commence. The lockdowns will end, and the disease will run hot and wild.
It is very unlikely at that point that there will be anything “United” about the United States at that point. What happens then is far more unclear, but none of it is good.
@New Deal democrat: As per what I’ve laid out here, he won’t have to. Love your blog, BTW.
Phase 4: Newly reissued Republican deficit hawks drown Phase 4 in the tub immediately after rushing Phase 3 into place.
@hitless: I expect the Trumpskis also noted that the Coronavirus is disproportionately attacking blacks and the poor – who trend Democratic. Just coincidental, I’m sure
@ziggy: IANAL but I recall from my Biz Law course that many states agree on model legislation and regulations as a substitute for national standards. Then there is what Gov. Newsom of CA did recently in organizing a multistate consortium for buying medical supplies.
Things like these make me think we can do something similar with lockdown policies.
A “model protocol” with a dozen founding states as members will provide some measure of coordination and perhaps save lives. It will also help individual governors withstand pressure to ease up prematurely–there is safety in numbers. Even though many timid and/or stupid governors won’t be early adopters, those that finally wise up will have an existing structure to join.
This does nothing to rationalize air travel and other functions better done at the federal level, but it buys time until we either get rid of trump by 2020 or just accept that we are going to wind up with many more deaths as we meander toward herd immunity.
Ha ha, good one. Wait, they were serious?
Logically, if we were going to return to something like “normal”, we would need LOTS of testing. Even here in New York, the epicenter of the epidemic in the US (at the moment) there isn’t widespread testing. For all I know, I could have had COVID-19 in mid March when I had a really bad respiratory sickness. I didn’t have a fever, I didn’t get tested, and now of course I won’t get tested because I’m not sick. How many people are there in my situation? How many of us might have had COVID-19 and not known it, and still not know it?
I’d guess this is mostly smoke. Trump and Barr are just saying “yay, cookies and ice cream for every meal!” so they can portray Democrats and those elitist “experts” as the mean ol’ mom who makes you eat stinky vegetables.
American politics is conducted at about a fifth-grade level … at best. Under Trump, it’s more like first or second grade.
@topclimber: Good thinking. A month ago, New York coordinated its efforts with New Jersey, Connecticut and (I think) Pennsylvania. I could see this happening on a larger scale in the northeast, and that would be better than the alternative.
@Chyron HR: Trump wants a payroll tax holiday, which — UNLIKE the one under Obama in 2009 — would apply to BOTH businesses and individuals instead of individuals only, because it would save his business (and those of his donors) big bucks, and as a secondary benefit it would starve Social Security of revenue.
This is just standard Republican impoverish-the-people economics.
Le Comte de Monte Cristo, fka Edmund Dantes
Art Laffer (an underreported personality that would yield incredible pay per click revenue if beaten to death with a baseball bat on video) used his superior intellect to propose that plan. Between shit like that and the dumbasses on Squawk Box on CNBC this morning worrying and worrying about bond pricing, ETFs and support for large entities while intoning that money “is eventually going to be there for Main Street, just be patient”, this government doesn’t deserve to survive.
@topclimber: Yes, this is what I would like to see if (when!) there is no good federal plan for re-opening. I’ve joked about a “Pacific Federation”–Washington, Oregon and California, maybe include Nevada? of liked-minded states, unlimited travel and commerce. Like you said, a successful roll-out could produce a national template. Or it could provoke Trump to try and squash it like a bug.
Le Comte de Monte Cristo, fka Edmund Dantes
How does a payroll tax holiday work to help when so many aren’t working? It’s like trickle-down on steroids.
We’re looking at lots of things. Incredible things. Things I have a very good feeling about. People are amazed at how well I understand these things.
This should help us get ready for reopening
@The Moar You Know: You’re freaking me out! A bit far-fectched I think, but not terribly so.
@Le Comte de Monte Cristo, fka Edmund Dantes: The goal is to save businesses money and to break social security.
The federal stockpile of PPE is nearly depleted according to an AP report. That might be understandable if it had been given to states, and they were sufficiently supplied until the stockpile was replenished. Obviously not the case. And here’s Trumpov talking about re-opening business. They can’t do one basic thing to protect this country.
If Bernie wanted to use his powers for good, he could start baselessly claiming that Trump sold the nation’s PPE stockpile and pocketed the money. It’s no worse than what he said about Clinton and it even has the added benefit that it’s probably true.
I’mma gonna stop you right there chief. Wilmer uses his powers for the sake of Wilmer. You already know he’ll be dragging his teeth to support Biden as it is. What makes you think he’s going to change his spots now?
(Yes I mixed a bunch of metaphors in there. Don’t care. Still rolling with it.)
In Massachusetts, they’re interviewing for contact tracers right now, and are going to be starting with known cases next week, hoping to get some clarity on where people have been “catching” Covid-19. While they’re waiting for a good fast testing regimen (the Abbot Labs stuff is lovely, but there are no effing supplies of the consumables, so we’re on the slow testing protocol at ~6K/day), and a good fast serological test so that we can clear people to go back to work, every damn thing for April and May — and in two towns plus the Boston Pride Parade and Pops, June — is cancelled.
The Commonwealth is functionally shut down through May 4; I warned my daughter that in all likelihood, the earliest they could reopen “live” school is May 26, and that they may not reopen at all, even for the 8th graders to graduate.
Are other states setting up contact tracing?
i like it.
@FlyingToaster: Rhode Island is trying to collaborate with SalesForce.com to develop contact tracing software, according to an announcement during Gov. Raimondo’s daily press conference yesterday. Optimistic projection is that an online system might be “up and running within the next few weeks.”
What I’m afraid will happen here is that at the end of April they’ll declare victory and say everything can reopen, and then by the end of May it’ll be “y’all have to close again” when the virus starts spreading again. It would be much better to stay closed for 2 or 3 months than to do open – close – open – close over and over again.
You could ask your doctor to order an antibody (blood) test for you. It’s not a diagnostic test, so you won’t be using up scarce resources, but it could offer some clarity.
@sdhays: you’re right.