Road Map to “Reopening.” Part 1.

NYC across the Hudson

On Sunday, March 29, 2020, a team led by former Food and Drug Administration commissioner Scott Gottlieb, released a “road map to reopening.” The report, written by former FDA officials and experts from the Johns Hopkins Center for Health Security, lays out a path for an end to our national response to this crisis. It does so in three phases:

PHASE 1: During Phase 1, which we are in now, we use “population-based mitigation,” or community isolation, i.e., closing “non-essential” businesses (ex. restaurants, bars, hair cutters, museums and gyms), places of mass gatherings (ex. schools, concerts) and asking everyone to stay home and cancel all nonessential travel and mass gatherings. This slows the spread of the virus and buys time to flatten the curve of the epidemic, increase testing capability and surge the hospital capacity we will need to transition to Phase 2.

PHASE 2: During this phase, we can move, on a state-by-state basis, to “case-based interventions,” or isolating individuals — using mass testing and contact tracing to isolate those who are infected, while allowing healthy people to go about their lives, much as South Korea has done.

The trigger for the transition from community to individual isolation will be when a state has shown a sustained reduction in cases for 14 days. A state must also have the capability in place to test everyone with symptoms, conduct active monitoring of those who test positive and their contacts, and safely treat everyone who requires hospitalization. This, Gottlieb and his team say, will require that we establish a national capacity to conduct at least 750,000 tests a week, and that we roughly double the number of acute-care beds and ventilators available to treat patients across the country.

Once these benchmarks are met, individual states can begin to slowly relax social distancing measures. Those with confirmed cases would be isolated for at least seven days, and their confirmed contacts would be quarantined and monitored for at least 14 days. The rest of us could return to work and to school. However, even in this phase, life would not fully return to the way it was before the virus. The team recommends that individuals who can telework continue to do so, social gatherings still be limited to fewer than 50 people, and people maintain increased hygiene standards and even wear masks in public. And those at the highest risk—including the elderly and those with underlying conditions—would be asked to maintain social distancing until an effective treatment is developed.

If a state saw a sustained rise in cases for five days, Gottlieb and his team say, it should revert to Phase 1 and reinstate population-based mitigation. And while some states will be able to make the transition from community to individual isolation soon, the hardest-hit places where cases are still rising may need to maintain population-based mitigation for longer.

PHASE 3: Once an effective treatment—or better yet, a vaccine—becomes available, we can move to Phase 3 and lift all restrictions. At this point, we can begin to deal with this new coronavirus in the same way we deal with other viruses, such as seasonal flu.

Those writing, backing and promoting this “roadmapare sincere, well-meaning, knowledgeable (about health and epidemics) folks. They say “This is the sustainable strategy to defeat the virus that Trump has been demanding. It answers the key question on the mind of everyone whose livelihoods and businesses have been devastated: When and how does this nightmare start to end?” The answer, according to Gottlieb’s team, is that “if we maintain social distancing guidelines through April 30 as Trump has ordered, the chains of epidemic spread can be broken, allowing some states to transition in May.

Okay, I have some questions: 1. I understand that the use of the term “road map” is meant to signify that we have a starting point, a direction, a route, and a destination. The big problem is, we don’t have a model of the territory itself. When we use a roadmap—or these days, GPS—we do so with a reasonable expectation that the territory has been accurately represented or modeled. In a disease pandemic, by definition, we don’t know who has it a-symptomatically, to whom it was spread, who is a carrier or where it will strike next. That is the territory of a disease pandemic. 2. We are essentially charting the territory as we go—meaning all the numbers, like “750,000”, “14 days” and “fewer than 50 people”— are by necessity arbitrary. While most of us logically know this, and (for now) need to accept the validity of those guidelines, doesn’t there also need to be, incorporated into the plan, triggers for modifying any of the numbers? 3. If the answer to #2 is “yes”, we then confront perhaps our biggest problem: Triggers for modifying the plan will usually be based on local conditions (ex. what NYC—10,000 hospitalized, 1,562 deaths—needs is not what Spokane—17 hospitalized, 2 deaths—needs), but during a pandemic in our interconnected modern world, nothing is local! For example, I can’t get a haircut within walking distance of my apartment, but I can drive to Seattle and walk the streets, either getting infected or infecting others!

The last time our country instituted national and state quarantines was 1918. That year and the following, 25 million Americans became sick with the flu and an estimated 670,000 people died. It was one of the worst epidemics the country has ever faced. In the 102 years since that last time, what has changed? That question will be the focus of part two. The official report contains one final phase—Phase 4, “prepare for the next pandemic.” Because this virus won’t be the last.

What am I recommending? See parts 2 and 3 of this post, published tomorrow.

Before you go to that, let’s deal with a huge question: Has our country done a worthwhile job up to now? As the number of coronavirus cases has grown in the United States–and is now the highest of any country–one of the themes of the critics is that this increase is the result of the incompetence of President Trump and his administration. Last Sunday, Chuck Todd of NBC asked Joe Biden whether President Trump has “blood on his hands” because of the U.S. failure to properly deal with the coronavirus crisis. 

One of the flaws in these claims and accusations is they fail to account for the size of the U.S. population in relation to others. The United States is the third-largest country in the world by population, behind only China and India. There are reasons to doubt China’s reports on its management of the virus, and India is just beginning its bout with this deadly disease. In other words, on the basis of population alone, the United States should have one of the highest absolute numbers of coronavirus cases.

According to the Worldometer, a private statistical resource used by Johns Hopkins University, the New York Times and others, as of April 1, the United States had 188,881 cases and 4,066 deaths, for a total fatality rate of 2.15%. That is the one of the lowest fatality rates among the world’s major developed countries. In the world as a whole, according to Worldometer, by April 1 there had been a total of 884,075 coronavirus cases, resulting in 44,169 fatalities, for a world fatality rate of 4.99%. This is much higher than the U.S. rate, but the fairest test of the success of the Trump administration would be to compare the U.S. fatality rate to that of other developed counties on the same date. Here is the comparison:

China: 81,554 cases, 3,312 fatalities, for a rate of 4.06%
Italy: 105,792 cases, 12,428 fatalities, for a rate of 11.7%.
Germany: 74,508 cases, 821 fatalities, for a rate of 1.1%
UK: 29,474 cases, 1,789 fatalities, for a rate of 7.95%
South Korea: 9,887 cases, 165 fatalities, for a rate of 1.67%
Switzerland: 17,137 cases, 461 fatalities, for a rate of 2.69%

Thus, the U.S. fatality rate ranks among the lowest of any developed country, bettered only by Germany and South Korea, and well ahead of China, Italy, Spain, France, Sweden, and the United Kingdom.

In addition, the number of “cases” in the United States does not reflect the total number of people who have contracted the coronavirus but remain asymptomatic and have not sought testing. It’s important to note that the U.S. government has consistently asked those without symptoms not to seek testing, because the priority has been to identify people who may need hospitalization. Thus, the number of coronavirus “cases” in this country is likely to be substantially larger than the number of people who were actually tested and became “cases” in that way. If people who have been exposed to the virus and are asymptomatic had been tested, that would have driven the U.S. percentage of fatalities far lower.