3 steps to ending the COVID-19 lockdown — and why we're not prepared for them

Test. Trace. Isolate.

As talk turns to how the United States can at least somewhat safely reopen its economy amid the world’s largest and deadliest coronavirus outbreak, this three-part strategy has become the closest thing to a consensus among experts, epidemiologists and even the Wall Street executives on President Trump’s newly formed economic task force.

That’s the good news.

But there’s bad news too. According to the latest data, the U.S. is nowhere near being able to test or trace at the scale necessary to transition out of lockdown. Meanwhile, Americans have yet to accept the idea that isolation will continue to be a part of everyday life.

We won’t be ready to reopen until that changes.

The basic concept of test-trace-isolate is simple. Right now, the U.S. is successfully slowing down the coronavirus outbreak. That’s because more than 95 percent of the U.S. population is currently living under lockdown orders.

A man holds a sign reading "Set us free"
A protester at the state Capitol in Lansing, Mich., on Wednesday. (Paul Sancya/AP)

Without widespread immunity, the coronavirus will start to spread as soon as social-distancing measures are lifted. Hundreds of thousands or even millions of Americans could die. That’s where test-trace-isolate comes in. The more people you can test — both for current infections and the antibodies created by prior infections — the more accurately you can determine who’s safe from the virus and who’s spreading it to others. The more robust your ability to trace the movements of people infected with the virus, the more rapidly and comprehensively you can inform everyone they’ve come in contact with. And the more you can do that, the more everyone can isolate and stop spreading the virus further.

This is epidemiology 101. But when you compare where we are today to where we need to be, the gap is startling.

Take testing. Experts disagree about how many tests we’d need to do per day to conduct effective coronavirus “surveillance” in a post-lockdown America. Nobel Prize-winning economist Paul Romer says 22 million or more. The Edmond J. Safra Center for Ethics at Harvard University says “millions” (at least). Five hundred thousand is generally considered the bare minimum required just to test everyone with symptoms and their close contacts.

During the week of April 6, the U.S. averaged 150,000 tests per day.

This isn’t a backward-looking blame game about the testing lapses that made America’s coronavirus outbreak worse than it had to be. It’s about what happens next. We’ve made a ton of progress since early March, when daily tests numbered in the hundreds. But that progress has basically stopped. So far this week we’re actually averaging fewer tests per day — 145,000 — than last week. Why? Because we’re running out of swabs, pipettes and chemicals, according to commercial labs.

And ramping up will only get more challenging from here.

“Many gains were made by getting players into fight (clinical labs, academic labs),” Scott Gottlieb, a former commissioner of the Food and Drug Administration, recently explained on Twitter. “Now we must expand lab capacity, platforms, throughput, test kits. Getting next million tests/week will be harder than getting first.”

Even as Trump brags at his daily briefings that America has “the most expansive testing system anywhere in the world” — fact check: We rank behind Germany, Italy, South Korea and Canada in tests conducted per capita — officials in Washington seem to recognize how much more we need to do.

According to a national reopening strategy drafted for the Trump Administration by experts at the Federal Emergency Management Agency and the Centers for Disease Control and Prevention, the government is considering a three-phase timeline: preparing the nation to reopen (now to May 1), aggressive testing (now to May 15) and a “staged re-opening (“not before May 1”). Note the second phase.

President Trump speaking
President Trump speaks about the coronavirus in the Rose Garden of the White House on Wednesday. (Alex Brandon/AP)

And on Wednesday, Senate Democrats released a $30 billion plan for building up what they called “fast, free testing in every community,” saying they would push to include it in the next pandemic relief package. It’s unclear how Republicans will respond.

“The more testing, the more open the economy. But there’s not enough national capacity to do this,” New York Gov. Andrew Cuomo, a Democrat, said Wednesday at his daily briefing in Albany. “We can’t do it yet. That is the unvarnished truth.”

Behind Cuomo, a PowerPoint slide read, “WE NEED FEDERAL SUPPORT.”

Contact-tracing is the second step. Even if daily testing more than triples by May the U.S. will need a nationwide system for tracing and mapping contacts so those tests can actually save lives. The road is steep here as well.

“The concept is: once you get down to a manageable number of cases and scale up the public health system, then you will be able to pounce on any case or cluster to proactively identify cases, identify contacts, and follow up on those contacts,” Tom Frieden, a former director of the CDC, told STAT news recently. “When you get those things done, you can prevent the clusters from becoming outbreaks, prevent outbreaks from becoming epidemics, and prevent the epidemics from driving us into our homes again.”

“It is going to be critical," current CDC Director Robert Redfield added in a recent NPR interview. “We can’t afford to have multiple community outbreaks that can spiral up into sustained community transmission — so it is going to be very aggressive, what I call ‘block and tackle, block and tackle.’”

Redfield went on to say, “We have over 600 people in the field right now from CDC in all the states trying to help with this response.” A new report by public health researchers at Johns Hopkins and the Association of State and Territorial Health Officials (ASTHO) says that “currently only 2,200 DIS [disease investigation specialists] are employed throughout the entire country in local and state health agencies.”

That’s fewer than 3,000 contact tracers, total. To put this number in perspective, the ASTHO and Johns Hopkins report estimates that the U.S. needs at least 100,000. To match the level of tracing done in Wuhan, China — where more than 1,800 teams of epidemiologists, with a minimum of five people per team, were tracing tens of thousands of contacts a day — we would need at least 265,000. And Frieden goes even further. “We need an army of 300,000 people,” he told STAT.

Government officials recognize the challenge they face. “We are going to need a substantial expansion of public health fieldworkers,” Redfield told NPR. “We’re far along in those planning processes as we speak.” But he also said it was “premature” to specify how much staffing the CDC plans to put in place and suggested that state and local public health departments — already severely strained by the pandemic — would have to take the lead.

Technology should help. South Korea and Taiwan modernized contact tracing with geolocation data from patients’ Bluetooth or GPS-enabled smartphones or both, and Apple and Google have partnered on a “Bluetooth-based contact tracing platform” and “application programming interfaces (APIs) and operating system-level technology to assist in enabling contact tracing.” Third-party apps will follow (though they may be less comprehensive than their Asian counterparts because of U.S. civil liberties concerns).

Public-private recruitment efforts will play a part as well. In Massachusetts, for instance, Partners in Health is working with state officials to hire nearly 1,000 contact tracers, who need only a high school diploma.

A certified medical assistant places a swab into a vial
A medical assistant places a swab into a vial for one of the first 50 people tested for the coronavirus at the first drive-through testing site in Flint, Mich., on Wednesday. (Jake May/The Flint Journal, MLive.com via AP)

Isolating Americans who are infected, or may have come into contact with someone carrying the virus, is one more hurdle. How will Americans who have just emerged from months of lockdown respond when told that they have to isolate again because they’ve crossed paths with an infected person, or that their entire community has to return to lockdown if and when the virus resurges in the cooler fall months?

Already, protesters are taking to the streets in several states to urge governors to reopen businesses and relax stay-at-home orders. On Wednesday, thousands of honking and flag-waving demonstrators participated in a protest called “Operation Gridlock” on the grounds of the state Capitol in Lansing, Mich. “Live Free or Die,” “Make Michigan Work Again” and “We Deem Our Governor Non-Essential,” read their signs. In Frankfort, Ky., dozens of people pressed against a Capitol window to hurl epithets at the governor, who was inside holding a coronavirus briefing. And in Raleigh, N.C., a woman was arrested Tuesday after violating the state’s stay-at-home order at a protest that drew at least 100 people. Small-government conservative groups are planning further protests in Texas, Oregon and Washington.

Social distancing is here to stay — at least until a vaccine arrives. Life will be different for a long time. Some of us will have to isolate again (and again). Until America accepts that, it doesn’t matter how much we want the country to reopen. We won’t be ready.


Click here for the latest coronavirus news and updates. According to experts, people over 60 and those who are immunocompromised continue to be the most at risk. If you have questions, please refer to the CDC’s and WHO’s resource guides.

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